Radiotherapy: 40 years from tracing paper to tomotherapy

NHS

Physicist Andy Moloney and Clinical Oncologist David Morgan reflect on how radiotherapy developed since their early careers

 

We first met in the autumn of 1981, when the NHS was, at 33 years from its inception, but a youngster. Andy had recently joined the Radiotherapy Physics staff at Nottingham General Hospital after graduating in Physics from the University of Nottingham, and David was returning to the clinical Department of Radiotherapy and Oncology after a year’s Fellowship at the Institut Gustave-Roussy in France. A firm friendship rapidly developed, one that continues to this day.

On reflection, joining the radiotherapy fraternity at that time was a leap of faith. The perceived wisdom amongst many of our scientific and clinical colleagues at the time was that this treatment technique was outdated and overshadowed by radical surgical procedures, new chemotherapy agents and biological modifiers poised to reduce radiotherapy to the history books.

picture 063This was a time when, in this Cinderella of specialties, physics planning was achieved by the superposition of two dimensional radiation plots (isodoses) ,using tracing paper and pencils, to produce summated maps of the distribution. The crude patient outlines were derived from laborious isocentric distance measurements augmented by the essential “flexicurve”. The whole planning process was slow and labour intensive fraught with errors and ridiculed by colleagues in the perceived prestigious scientific and clinical disciplines. The principal platform for external beam radiotherapy delivery, the Linear Accelerator (LinAc), had also reached something of a plateau of development, albeit with improved reliability, but few fundamental changes. Caesium tubes were transported from the “radium safe”, locked in an underground vault, to the operating theatre in a lead-lined trolley, where they were only loaded into “central tubes” and “ovoids” after the examination under anaesthetic (which was performed with the patient in the knee-chest position); they were then manually placed into the patient, who went to be nursed on an open ward, albeit behind strategically placed lead barriers.

For no sites outside the cranium was Computer Tomography (CT) scanning available. Magnetic Resonance Imaging (MRI) was still a vision seen only by a small number of enthusiasts.

All these limitations were met by a developing team of scientific and clinical enthusiasts believing in the future of radiotherapy if only technology could deliver solutions to address an improving understanding of the differing cancers and their radiobiology.

picture 066In the latter half of the eighties these solutions began to crystallise. Computers were being introduced across the NHS and their impact was not lost in radiotherapy. Pads of tracing paper were replaced with the first generation of planning computers. The simple “Bentley-Milan” algorithms could account for patient outlines accurately and speedily and optimising different beam configurations became practical. Consideration of Organs at Risk, as defined by the various International Commission on Radiation Units (ICRU) publications, became increasingly relevant. Recognition of the importance of delineating the target volumes and protecting normal tissue required improved imaging and this was provided by the new generation of CT scanners. In the nineties these were shared facilities with diagnostic radiology departments. However, the improvements provided by this imaging, enabling accurate 3-dimensional mapping of the disease with adjacent normal tissues and organs at risk, dictated their inclusion into every radiotherapy department soon after the millennium. The added bonus of using the grey scale pixel information, or Hounsfield numbers, to calculate accurate radiation transport distributions soon followed when the mathematical and computer technology caught up with the task. The value of MR and Positron Emission Tomography (PET) imaging was also recognised in the diagnosis, staging and planning of radiotherapy and the new century saw all of these new technologies embedded within the department.

Mould room technology was also improving with “instant” thermoplastic immobilisation shells replacing the uncomfortable plaster and vacuum forming methods. Custom shielding with low melting high density alloys was becoming routine and it was not long before these techniques were married with the emerging CT planning to provide “conformal” treatments.

picture 067LinAc technology also received added impetus. Computers were firstly coupled as a front end to conventional LinAcs as a safety interface to reduce the potential for “pilot error”. Their values were soon recognised by the manufacturers and were increasingly integrated into the machine, monitoring performance digitally and driving the new developments of Multi Leaf Collimators (MLC) and On Board Imaging (OBI).

The dominos for the radiotherapy renaissance were stacked up, but it needed the radiographers, clinicians and scientists to decide on the direction of travel. Computer power coupled with advanced electro-mechanical design had transformed MLC efficiency and resolution. Conventional conformal planning was now progressively superseded by sophisticated planning algorithms using merged CT and MR images. Intensity Modulated RadioTherapy (IMRT) had arrived in its evolving guises of multiple fixed field, dynamic arc therapy (RapidArc) or Tomotherapy. Whichever technique, they all offered the radiotherapy “Holy Grail” of providing three dimensional homogeneous dose distributions conformed to the Planning Target Volume (PTV) whilst achieving the required dose constraints for organs at risk and normal tissue preservation.

The tools had arrived, but an infrastructure to introduce these “toys” safely into a complex clinical background had also developed alongside. Quality standards (ISO9000), Clinical Trials, Multi Disciplinary Teams and Peer Review were governance mandates for all oncology departments and radiotherapy was leading the way. In forty years, radiotherapy had lost the “Cinderella” image and had been invited back to the clinical ball. Noticeably, breast and prostate adenocarcinoma constituted half of the radical workload.

The question remains of how and why did this transformation occur? Obviously the developing computer power and technology were the pre-requisites for many of the developments, but a key catalyst was the foresight of all of the radiotherapy family from which enduring friendships have been forged. The working lives of the clinicians and physicists involved in radiotherapy planning have probably changed more dramatically than those of any other medical and paramedical groups over the last 35 years.

We may have retired, but we still cogitate about the future direction and science behind this developing and essential cancer treatment and look forward to our younger colleagues enjoying their careers as much as we enjoyed ours.

 


About David Morgan

david morganDr David A L Morgan began training in Radiotherapy & Oncology as a Registrar in 1977, and in 1982 was appointed a Consultant in the specialty in Nottingham, continuing to work there until his retirement in 2011. He joined the BIR in 1980 and at times served as Chair of its Oncology Committee and a Member of Council. He was elected Fellow of the BIR in 2007. He is author or co-author of over 100 peer-reviewed papers on various aspects of Oncology and Radiobiology.

 

About Andrew Moloney

andy moloneyAndy Moloney completed his degree in Physics at Nottingham University in 1980 before joining the Medical Physics department at the Queens Medical Centre in the same city. After one year’s basic training in evoked potentials and nuclear medicine, he moved to the General Hospital in Nottingham to pursue a career in Radiotherapy Physics and achieved qualification in 1985. Subsequently, Andy moved to the new radiotherapy department at the City Hospital, Nottingham, where he progressed up the career ladder until his promotion as the new head of Radiotherapy Physics at the North Staffordshire Royal Infirmary in Stoke-on-Trent. Over the next twenty years Andy has acted as Clinical Director for the oncology department and served on the Radiation Physics and Oncology Committees at the BIR and was appointed a Fellow in 2007. He has been the author and co-author of multiple peer reviewed articles over the years prior to his retirement in 2017.

 

Has imaging become too effective?

Adrian Dixon

Professor Adrian Dixon has a worldwide reputation as an academic and a radiologist and has published extensively on body and musculoskeletal CT and MR imaging.

He will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Read this fascinating interview with him and get a taster of this “not-to-be-missed” presentation.

You will be delivering the BIR Toshiba Lecture at UKRC this June. Your lecture is called “Has imaging become too effective?” Can you give us a “taster” of what you mean by this?

“You should say what you mean!” as the March Hare said in “Alice’s Adventures in Wonderland”.

What do people mean by “effective”? Effectiveness is only an appropriate term if qualified. Modern imaging certainly is effective at increasing the diagnostic confidence about a diagnosis and excluding certain diagnostic possibilities. It has taken a long while to prove that it is effective in saving lives. It has become so effective that, in many conditions, an image can be rendered to make the diagnosis obvious to the man in the street.

And clinicians now tend to refer for imaging without stopping to think! It has also become so effective in demonstrating probably innocuous lesions that the worried well can become even more of a hypochondriac! In some societies this can lead to over usage, excessive radiation exposure and increased costs.

If imaging is “too effective” – is radiology still a worthwhile career choice?

Yes! It is the most fascinating of all medical careers and every day a radiologist should see something that he or she has never quite seen before. The radiologist is the ultimate medical detective and cannot conceivably get bored. Indeed radiologists get reimbursed to solve crossword puzzles on elaborate play stations!

What have been the three biggest challenges for you in your career?

Radiologists have had to learn and relearn their skills at frequent intervals during their careers. Radiology will only survive as a specialty if the radiologist knows more about the images, the technical aspects and the interpretative pitfalls than their clinical colleagues.

Did you ever meet Godfrey Hounsfield (inventor of CT imaging) and what were your memories of him?

opening of scannerI did indeed meet Sir Godfrey on numerous occasions. His humility and “boffin style” of science greatly appealed. Some of the stories at the numerous events surrounding his memorial service were truly fascinating, including his inability to accept any machine which he could not understand without taking it to bits and then reassembling it!

 

Given the financial pressures on healthcare, will the required investment in the latest imaging technology be affordable?

Some of the developments in personalised medicine may be unaffordable. Generic contrast agents will continue to be used in large volumes. The cost of creating “one off” agents may prove unjustifiable.

Why would you encourage someone to join the BIR?

Because of the fun of interdisciplinary discussion and the pride of being a small part of the oldest radiological society!

Does spending more money on equipment mean a better health service?

I passionately believe that prompt access to imaging makes a major contribution to excellent healthcare. But that does not necessarily mean that every hospital has to have every machine at the top of the range. A rolling programme of equipment replacement is an essential part of delivering a high-quality radiological service.

The most difficult thing I’ve dealt with at work is…

An electrical power cut during the middle of a tricky adrenal CT-guided biopsy!

If Wilhelm Roentgen could time travel to Addenbrooke’s hospital, what would he be most impressed with?

The sheer size and the number of staff of the radiology department!

When its 2050, what will we say is the best innovation of the 21st century in healthcare?

Data mining and health statistics.

Who has been the biggest influence on your life? What lessons did that person teach you?

All my previous bosses have influenced my career. I have learnt something from each of them. All of them stimulated me to ask the question “why are we doing things this way”? “Can it be done better”?

My proudest achievement is…

Helping to make the Addenbrooke’s Radiology department one of the most modern in the UK.

What advice would you pass on to your successor?

Never give up, try, try and try again and remember “the more you practice, the luckier you get”.

What is the best part of your job?

That I have been lucky to have had a succession of challenges in the various roles that I have held, all of which have kept me on my toes.

What is the worst part of your job?

Leaving salt of the earth friends as I have moved from role to role.

If you could go back 20 years and meet your former self, what advice would you give yourself?

Do not worry so much – it will all be alright on the night.

Adrian Dixon

Adrian Dixon

What might we be surprised to know about you?

That I support Everton Football Club.

How would you like to be remembered?

For influencing the careers of younger colleagues – hopefully to their benefit!

260215 opening

Professor Dixon will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Book your place at UKRC (early bird rate ends 15 April 2016)

 

Toshiba-leading-innovation-jpg-large Thank you to Toshiba for supporting the BIR Mayneord Eponymous Lecture

 

 

Looking back on the life of Professor Robert Steiner

image Robert Steiner

Professor Robert Steiner

Robert Emil Steiner CBE MD FRCP FRCR
BIR Past President
(born 1 February 1918, died 12 September 2013)

As the world of medical imaging moves on with great rapidity, we mustn’t forget those great pioneers who helped us achieve the breakthroughs we take for granted today.

Here, Professor Graeme Bydder of the University of California, San Diego, reflects on the life of the man he knew and admired.

Robert Steiner, former professor of Radiology at the University of London and chairman of the Department of Radiology at the Royal Postgraduate Medical School, Hammersmith died after a long illness on September 12, 2013 at the age of 95.

Professor Steiner established and ran the leading academic Department of Radiology in the UK for many years. He was president of both the British Institute of Radiology and the Royal College of Radiologists and had a major role in the development of cardiac and pulmonary angiography as well as that of magnetic resonance (MR) imaging.

He was born in Prague in 1918 which was then part of the Austro-Hungarian empire, and moved with his family to Vienna at the age of three. He began studying medicine at the University of Vienna in 1935. He was about to complete his preclinical studies at the time of Anschluss, the political annexation and military occupation of Austria by Nazi Germany on March 12, 1938. Members of his medical class who expressed an objection to this simply disappeared. He needed a further two months to complete the first part of his medical degree, and after doing this, escaped through Italy to Dublin in May 1938.
He finished his medical training in Dublin in 1941 and worked in the Emergency Medical Service in the UK from 1941 to 1945. He trained in radiology at the United Sheffield Hospitals from 1944 to 1950.

He was appointed Assistant Director of Radiology at Hammersmith Hospital, London in 1950. At that time much of the equipment in the department was of pre-war vintage and the Director had radiation damage to his hands. Over the next 10 years, Professor Steiner became Director, recruited new staff, replaced equipment and established a very active teaching program.

He was appointed the first professor of Diagnostic Radiology in the University of London in 1961. He established a research program concentrating on cardiac and pulmonary angiography. This was essential for the assessment of valvular disease in the newly developing speciality of cardiac surgery. He also encouraged senior faculty within the department such as Peter Lavender, David Allison, John Laws, and Thomas Sherwood to develop their own areas of expertise to international level.

Tutorials were held on Monday evenings often with radiologists from around London bringing problem films. They were also held on Friday afternoons at 5pm in case any trainees had the idea of going home early. Private practice was banned. This meant that there was generally more consultant time available for teaching and research than at other London teaching hospitals where this was not the norm.

Professor Steiner helped train a succession of radiologists who went on to occupy senior positions in departments throughout the world. These included John Laws (Kings College), Thomas Sherwood (Cambridge), Lenny Tan (Singapore), Constantine Metreweli (Hong Kong), Andy Adams (Guy’s and St. Thomas’s), Brian Ayers (Guy’s and St. Thomas’s), Maurice Raphael (the Middlesex), John Stevens (St. Mary’s and Queen Square), Dennis Carr (the Brompton), Gary Lawler (Melbourne), Tony Leung (Sydney), Nandita deSouza (the Royal Marsden), Peter Dawson (UCH), Walter Curati (Ealing), Derek Kingsley (Queen Square), Rolf Jager (Queen Square), Takayuki Ouchi (Chiba), Alina Greco (Monaco), David Robinson (Abergavenny), Adrian Thomas (Bromley), Mary Ann Johnson (Edmonton), Susan Peterman (Atlanta) and Steven McKinstry (Belfast).

There were also paediatricians (Lilly Dubowitz, Francis Cowan, Mary Rutherford, Linda de Vries and David Edwards), and physicians (John Brown, Mark Doran, Maria Barnard, Simon Taylor-Robinson) who benefited from his training. He strongly supported research radiographers (Jackie Pennock, Linda Banks, Di Spencer, Janet Sargentoni, Anne Case, Angela Oatridge, Susan White, Elaine Williams, and Serena Counsell), scientists (Jane Cox, Jimmy Bell, David Gadian, Richard Iles, Louise Thomas), psychiatrists (Basant Puri, Eve Johnstone, David Owens), and anaesthetists (David Menon, Carol Peden, David Harris), who worked within his department as well as Margaret Kirk, Patricia Hamilton and Dulcie Rodriguez.

Professor Steiner established very fruitful collaborations and exchanges with faculty of leading radiology departments in the United States, British Commonwealth and elsewhere in the world. He hosted numerous senior radiologists on sabbatical leave including Richard Greenspan (Yale), John Doppman (National Institutes of Health), Robert Fraser (Birmingham, USA), Ian MacKay (Hartford), Michael Vermess (NIH), Harold Davidson (Oklahoma), Bob Berk (University of California, San Diego) and Moshe Graif (Tel Aviv). These visitors made a substantial contribution to the department.

He was elected president of both the British Institute of Radiology (1972-73) and the Royal College of Radiologists (1977-80), as well as the Fleischner Society (1973) an international multidisciplinary society dedicated to the diagnosis and treatment of diseases of the chest. It was named after Felix Fleischner a chest radiologist who also left Austria after Anschluss, and worked at Massachusetts General Hospital.

During the 1950s and 1960s there was what seemed an inevitable shift in radiological leadership from Sweden to the US, but quite unexpectedly Sir Godfrey Hounsfield FRS produced the first head clinical computed tomography (CT) scanner in 1971. It was a spectacular success. This was followed by body CT scanners in 1974 and 1975, and the beginning of the modern era of radiology. Britain was at the centre of it, led by a company, EMI (Electric and Musical Industries Ltd) with a remarkable record in acoustics, electronics, TV and radar going back to Alan Blumlein in the 1930s, but no previous experience in the medical field or in x-ray technology.

This was followed by the initial development of MR imaging heralded by the first image published by Paul Lauterbur in 1973. Much of the subsequent development of the technique was performed by groups in the UK based in Aberdeen, Nottingham and London (EMI). There were many difficulties and the first international conference on MR imaging held at Vanderbilt University, Nashville on October 26-27, 1980 was only a limited success mainly due to the lack of convincing clinical results. What was necessary for MR imaging to receive the large scale investment needed for future progress was a major medical application in which the new technique had a substantial advantage over state of the art CT. This Professor Steiner achieved with Ian Young FRS and his team from EMI, in the MR imaging of plaques in the brain in multiple sclerosis (MS). These were shown on a scale not previously seen except at post mortem. MS was a disease that had not previously received significant radiological attention and it seemed an improbable starting point, but MS has since become the single disease of the body most studied with MR. The system the work was done on used the first whole body cryomagnet built by Oxford Instruments, a university spin-off company founded by Lady Audrey and Sir Martin Wood FRS.

The work was remarkable in other ways. During this period EMI sold its CT business to General Electric at a knock down price following its unsuccessful venture into the US, and was trying to sell its MR business. The Medical Research Council (MRC) closed down its CT operation at Northwick Park Hospital, London in 1980 and soon after closed down its ultrasound research there. The MRC would not support clinical MR work at Hammersmith and the leader of the Hammersmith MR group, Frank Doyle suffered a catastrophic stroke before clinical studies began, and never worked again. The only significant outside support came from Gordon Higson, Director of the Scientific and Technical Services Branch of the DHSS.

The success with MS was followed by other major applications of MR including diagnosis of disease in the posterior fossa (where CT was degraded by beam hardening artefacts, 1982-3), use of the heavily T2-weighted spin echo sequence which provided very high soft tissue contrast (1982), paediatrics (no ionizing radiation, 1982-3), the first clinical study with gadolinium-DTPA (opening up the MR study of intracranial tumours, where previously the use of intravenous iodinated agents had given CT a major advantage (1984), high contrast fat signal suppressed sequences for body and musculoskeletal applications (1985). These developments helped keep the UK at the forefront of clinical MR research until, and beyond the ISMRM (International Society for Magnetic Resonance in Medicine) meeting at the Barbican, London in 1985. It also provided time for other groups to mobilise including those led by Donald Longmore (the Royal Brompton), Ian Isherwood (Manchester), Donald Hadley (Glasgow), Ian McDonald, George du Boulay and David Miller (Queen Square), Ian Kelsey Fry (St. Bartholomews, London), Jonathan Best (Edinburgh), Paul Goddard (Bristol), Adrian Dixon (Cambridge), Peter Cavanaugh (Taunton), Stephen Golding (Oxford), Philip Robinson (Leeds) and others to add to the radiological work already done by Frank Smith (Aberdeen) and Brian Worthington FRS (Nottingham). Oxford Instruments expanded rapidly and captured most of the world market for whole body cryomagnets.

The success with MR showed that the earlier success with CT could be repeated, and major developments in other areas of radiology followed including remarkable advances in ultrasound, nuclear medicine, interventional radiology, PACS and digital radiography. These helped transform the speciality of radiology and create the modern era of imaging.

Professor Steiner contributed in many different ways to these developments. He brought to the many tasks he undertook very high standards, and a wide ranging strategic vision, but it was his sense of fairness and justice that endeared him to people at all levels, and led them to trust him without reservation on personal and professional matters.

He was appointed CBE and was the recipient of the gold medals of the Royal College of Radiologists and the European Society of Radiology. He also received honourary degrees, fellowships and memberships from universities and radiological societies around the world.

He was strongly supported by his wife Gertie. She is remembered with great affection as a gracious hostess as well as a source of encouragement and wise counsel by generations of staff, faculty and visitors to the department. Gertie and Robert met in Dublin and married in Sheffield in 1945. They had two daughters, Hilary and Ann. Hilary has two children Christopher and Sarah, and one grandchild. Ann has three boys Tim, Will and Bertie. Robert had two sisters, who together with their families escaped from Vienna to Australia where they settled, and a brother Herbert who studied physics at Cambridge, and remained afterwards in England. Robert’s father and stepmother spent the war years in France, then went to England before returning to Austria.

About Professor Graeme Bydder

Graeme Bydder was born in New Zealand in 1944 and trained in medicine at the University of Otago, Dunedin. He graduated in 1969. He subsequently trained in medicine in New Zealand under Keith Macleod before receiving a Nuffield fellowship to train in CT under Louis Kreel at the MRC Clinical Research Centre, Northwick Park Hospital, London in 1978. His main work was on CT attenuation values in fatty disease of the liver, iron overload, and bone disease.

He worked at the Royal Postgraduate Medical School, Hammersmith Hospital under Frank Doyle and Professor Steiner from 1981 onwards. His main research activity was technical development and clinical application of magnetic resonance (MR) imaging in conjunction with Ian Young FRS and his team.

Professor Steiner provided strategic and tactical direction for clinical MR imaging at Hammersmith from its inception in 1981 to his final retirement in 1998.

Graeme moved to the University of California, San Diego (UCSD) in 2003 and since then has worked on MR imaging of short T2 components in tissues, qualitative and quantitative approaches to MR imaging, and MR microscopy of the musculoskeletal system.

In addition to the benefitting from working under Professor Steiner, Graeme was fortunate enough to work for two of the “three wise men” (Louis Kreel, Frank Doyle, and Jamie Ambrose) who did early experimental work on Godfrey Hounsfield’s prototype CT system and advised the DHSS to proceed with development of the technique in 1969.