State-of-the-Art Equipment
Hoag Radiation Oncology is a technology-dependent medical specialty that
requires sophisticated computers and software, and high-energy linear
accelerators to deliver tailored therapeutic doses of radiation. Treatment
complications and outcomes can be significantly improved by use of the
right instrumentation and technological support.
Hoag's Radiation Oncologists and Medical Physicists use state-of-the-art
resources to develop three-dimensional treatment plans that deliver precise
radiation doses for each patient's individual course of radiation therapy.
At Hoag Family Cancer Institute, the latest in innovative treatment options
are available to deliver radiation therapy based on each patient's
specific clinical needs. These are facilitated by sophisticated imaging
using CT, MRI, and PET scans with the latest computer treatment planning systems.
Some of the advanced equipment and resources used at Hoag Family Cancer
Institute includes:
ViewRay MRIdian™ Linear Accelerator
The ViewRay MRIdian™ linear accelerator is the most advanced radiation
oncology tool available. Through the generosity of community donors Dean
and Gerda Koontz, Hoag was the second in California to acquire the MRIdian, and 16th in the nation.
Unlike conventional linear accelerators, the ViewRay MRIdian utilizes MRI
imaging in combination with a linear accelerator, which allows Hoag clinicians
to obtain real-time, high resolution images of a patient’s tumor
during treatment. If the tumor has shifted from movement in the bowels,
or by a patient’s breath, radiation delivery stops to avoid radiating
healthy tissue. This level of precision allows Hoag clinicians to deliver
a higher, potentially more effective, radiation dose while sparing healthy
surrounding tissue and improving upon side effects.
Traditionally, CT scans are taken before radiation treatment to help clinicians
map out where to align the radiation beam during sessions. This type of
imaging, however, does not usually take into account the normal functions
of the body such as breathing or movement in the gastrointestinal tract,
which can cause the tumor and/or normal tissues and organs to move from
day to day during treatment. As a result, the healthy surrounding tissue
are at a high risk of being damaged in the process.
MRI imaging allows Hoag clinicians to deliver targeted radiation, usually
in fewer sessions, while sparing healthy surrounding tissue.
The ViewRay MRIdian also allows Hoag clinicians to more precisely and effectively
treat tumors of the abdomen, like pancreas, liver and prostate. The MRI
imaging provides high quality soft tissue definition, providing a clear
treatment area.
High Dose Rate Brachytherapy - (HDR)
High Dose Rate Brachytherapy (HDR), also referred to as "internal radiation
therapy" is a radiation treatment allowing a small radioactive source
to be temporarily placed inside numerous types of tumors.
Under computer control the position and timing of source placement can
be precisely controlled, allowing the physician to shape the radiation
dose to the target. Because of the high dose rate characteristics, brachytherapy
treatments can often be delivered on an outpatient basis or with a minimal
hospital stay. HDR is used in the treatment of early breast cancer, gynecological
(GYN) cancers and less often in other areas of the body. The treatment
may be the only radiation given or may be in conjunction with "external
radiation therapy".
3D Conformal Radiation Therapy (3DCRT)
In the past, radiation oncologists could only plan using two dimensions
(width and length), due to the limitations in imaging technology. With
current advanced imaging and computer technology, radiation oncologists
can plan treatment in three dimensions (width, height and depth). This
process is known as 3D Conformal Radiation Therapy (3DCRT).
The process starts with a CT scan, which gives a three dimensional picture
of the patient's body, including the tumor to be treated as well as all
normal anatomy. This picture may be supplemented with additional information
from other 3D images such as PET or MRI scans. Using this picture as a
map of the body, the radiation oncologist identifies a target to be treated
and any sensitive healthy tissue that needs to be avoided. The radiation
oncology team then uses powerful computers to design a radiation plan
with multiple beams aimed at the target. Each beam is shaped to deliver
the maximum dose possible to the target, while avoiding surrounding sensitive
structures. Thus, the radiation "conforms" to the target volume. 3DCRT
can be very useful when a tumor is close to a sensitive normal structure.
(For example, lung cancer close to the spinal cord.) The added precision
of 3DCRT allows the radiation oncologist to give more dose to the tumor
while limiting exposure of normal tissue to safe levels.
4-D CT Simulation
Since many lung tumors move as a patient breathes, this issue must be taken
into account when developing an effective radiation treatment plan. That’s
why at Hoag, patients who have tumors that may move with respiration are
imaged using state-of-the-art 4-D Computed Tomography (CT).
By utilizing innovative 4-D CT technology, Hoag Radiation Oncologists are
able to more accurately take respiratory motion into account when planning
radiation therapy. This enables oncologists to more accurately target
the cancer and spare healthy tissue during radiation treatments.
CyberKnife®
Hoag is proud to offer CyberKnife® as a technologically advanced treatment
option in the fight against cancer.
In collaboration with Newport Diagnostic Center (NDC), Hoag Family Cancer
Institute offers another minimally-invasive treatment option as part of
our comprehensive, personalized and integrated approach to cancer treatment.
The CyberKnife® offers a renewed sense of hope to patients who may
not be surgical candidates, while often providing an excellent adjunct
therapy for those patients undergoing cancer surgery.
The CyberKnife is an FDA-cleared, non-invasive, robotic radiosurgery system
that treats both cancerous and non-cancerous tumors with sub-millimeter
accuracy. In the care of Hoag-affiliated Radiation Oncologist Amanda Schwer,
M.D., patients are treated in single or fractioned doses (typically in
1-5 sessions) by delivering multiple beams of precisely directed radiation
that converge upon the tumor, minimizing damage to surrounding healthy
tissue. With the unique ability to provide sub-millimeter precision and
thereby spare healthy tissue, the CyberKnife is often capable of safely
delivering curative doses in cases which were previously considered untreatable.
The CyberKnife is capable of treating tumors and lesions located in the
brain, spine, prostate, lung, liver and pancreas; virtually anywhere in
the body.
Should your patient be faced with a cancer diagnosis, you can be assured
that Hoag will deliver the best treatment option for each specific patient.
Hoag also offers other minimally-invasive alternatives to surgical cancerous
tumor removal including Gamma Knife Perfexion®. Hoag has one of the
only Gamma Knife Perfexions® in Southern California and is the only
provider in Orange County offering both the CyberKnife and the Gamma Knife;
the two most technologically advanced stereotactic radiosurgery systems
in the world.
Through this new alliance, Hoag and Newport Diagnostic Center are jointly
providing CyberKnife radiosurgery in Newport Beach at 1605 Avocado Avenue.
Newport Diagnostic Center established the world’s first outpatient
CyberKnife center and has been delivering CyberKnife treatments to qualified
patients since 1996.
Dedicated CT Scanner
CT scanners are important because they provide the detailed anatomical
information. Using this 3D information the radiation oncologist can identify
the area to be treated and allow the medical dosimetrists to create a
plan precisely targeting the tumor and protecting the normal, healthy
tissue. Hoag Radiation Oncology has its own high-speed spiral CT scanner,
specifically designed for radiation oncology patients, located in the
department.
Gamma Knife Perfexion™
Hoag is proud to present Gamma Knife Perfexion, the most advanced and specialized
radiation machine for Stereotactic Radiosurgery (SRS). Hoag is the first
in Southern California to install the premier unit and continues to be
the only facility offering Gamma Knife Radiosurgery (GKRS).
Gamma Knife is the most well studied and published technique for delivering
SRS and Perfexion is a revolutionary improvement on the existing technology.
As compared to previous Gamma Knife units, the Gamma Knife Perfexion has
a cylindrical collimator system that increases the ability to treat lesions
independent of their location in the brain. The system also greatly improves
patient comfort.
Additionally, the Gamma Knife Perfexion has been configured for maximal
shielding outside of the treatment region, which greatly reduces unwanted
exposure to the patient. And, the unique collimator system allows for
custom configurations, greatly expanding the ability to shape radiation
dose to conform to the target volume increasing the capability of sparing
larger areas of normal, healthy tissue. The many technological advances
of the Gamma Knife Perfexion translate into a safer, more accurate, and
more comfortable treatment.
Hoag has a distinct advantage with active SRT/SBRT and SRS programs in
the same facility. Our weekly multidisciplinary Neuro-Oncology Tumor Board
specialists are therefore able to recommend and carry out optimal treatment
regimens within this fully integrated facility assuring the patients the
best possible treatment options.
For more information, please visit Hoag Gamma Knife Center​.
Image-Guided Intensity-Modulated Radiation Therapy (IG-IMRT)
Intensity-Modulated Radiation Therapy (IMRT) uses intricately shaped beams
to enhance the techniques used in 3D Conformal Radiation Therapy (3DCRT).
In 3DCRT, intensity of the radiation is uniform throughout the shape of
the beam. With IMRT, the radiation intensity is non-uniform throughout
the beam shape. This non-uniform intensity allows for better control in
shaping the radiation delivered to the target volume, while avoiding healthy
tissue. (For example, when treating a head and neck cancer while trying
to avoid nearby salivary gland and spinal cord.) The complex shaping of
radiation using IMRT adds to the capabilities of 3DCRT, and allows the
radiation oncologist to give more dose to the tumor while limiting exposure
of normal tissue to safe levels.
IMRT can be further enhanced with the use of image-guidance (IG-IMRT).
One problem that a radiation oncologist faces is how to position the patients
properly for their daily treatments. Tumors aren't always where they are
expected because of movement with breathing, expansion of the gastrointenstinal
tract with air or other similar factors. In IG-IMRT, an image is taken
daily prior to the radiation treatment, and changes in set up are made
to ensure that the tumor is targeted appropriately. (For example, to help
visualize the target, the radiation oncologist may implant metal markers
in the prostate gland.) Our Varian 21EX uses a digital imager to visualize
metal markers in a 2D fashion on a daily basis. Alternatively, some machines,
such as Tomotherapy, can take a 3D image that shows the tumor and the
surrounding anatomy directly in order to achieve the appropriate set up.
Such image-guided techniques make treatment more accurate, ensuring that
radiation is directed at the appropriate target and away from the adjacent
healthy tissue.
IMPAC Radiation Oncology Management System
This system provides the department with an electronic medical record specifically
for each patient's radiation oncology visits. It provides the tools necessary
for managing patient scheduling, billing and records. This computerized
system also gives the treatment units the additional verification and
documentation of all treatment deliveries, providing a greater level of
treatment accuracy on a daily basis.
Linear Accelerators
Linear Accelerators are devices that produce high energy x-rays by using
electromagnetic waves to accelerate charged particles. The three computer
controlled accelerators at Hoag Cancer Institute are equipped with differing
energies and devices making them capable of delivering specialized cancer
treatments. Each machine has varying capabilities thus allowing the radiation
oncologist to choose the best treatment for each patient. Hoag's tomotherapy
unit is a specialized treatment machine that is a linear accelerator mounted
on a CT scanner and is used for Image-Guided Intensity-Modulated Radiation
Therapy (IG-IMRT), and Stereotactic Radiation Therapy (SRT) / Stereotactic
Body Radiation Therapy (SBRT).
Our Varian 21EX has a multileaf-collimator that can shape the beam using
movable leaves within the head of the machine and also includes an Electronic
Portal Imager that may be utilized for image-guided treatments. This type
of accelerator is ideally suited for 3D Conformal Radiation Therapy (3DCRT)
and Image-Guided Intensity-Modulated Radiation Therapy (IG-IMRT).
Our Elekta Infinity also has a multileaf-collimators that can shape the
beam using movable leaves within the head of the machine to conform to
the field shape. This type of accelerators is ideally suited for 3D Conformal
Radiation Therapy (3DCRT) and Volumetric Arc Therapy (VMAT).
Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET)
MRI and PET are important tools in the detection and treatment of some
cancers. They can detect small differences in the soft tissues of the
body which are not seen on CT scans. In Hoag Radiation Oncology, we use
these scans in conjunction with the CT scan to more accurately plan patient
treatment. This process is referred to as image fusion and allows the
physicians and physics staff to identify a patient's tumor and the normal
structures surrounding the tumor with greater precision and sophistication.
Hoag's staff of radiologists are renowned for their work in MRI, PET and
MR Spectroscopy and are available for patient consultation with the radiation
oncologists as they plan treatment..
Nucletron V2 Oncentra Planning System
Hoag Family Cancer Institute provides High Dose Radiation (HDR) services
for the brachytherapy treatment of cancer. HDR is a radiation treatment
allowing a small radioactive source to be temporarily placed inside numerous
types of tumors. Under computer control the position and timing of source
placement can be precisely controlled, allowing the physician to shape
the radiation dose field. Because of the high dose rate characteristics,
brachytherapy treatments can often be delivered on an outpatient basis
or with minimal hospital stay.
Philips Pinnacle Treatment Planning Computer
The treatment planning computer is central to the design of a patient's
radiation therapy plan. Using information gathered from MRI, PET, CT and
x-ray images, the treatment planning computer creates 3D models of a patient's
tumor and anatomy. Decisions about the how to deliver the radiation to
the targeted area can be developed in a virtual reality environment.
The medical dosimetrist will prepare treatment plans and calculate the
dose to meet the requirements of the physician's prescription. The radiation
oncologists and medical physicists will then review the treatment plans
and approve the most appropriate. The Philips Pinnacle Treatment Planning
Computer is among the most sophisticated computers available, with capabilities
to create 3D Conformal Radiation Therapy (3DCRT) and Image-Guided Intensity-Modulated
Radiation Therapy (IG-IMRT) plans. Software tools such as image fusion
and virtual simulation enable a patient's treatment plan to be developed
with the latest technology and greatest precision.
SpaceOAR
SpaceOAR® hydrogel is the first FDA cleared spacing device to protect
the rectum in men undergoing radiation therapy for prostate cancer. Hoag
is the first hospital in Southern California, and west of Mississippi,
to offer this revolutionary product, and is pleased to offer to patients
in both Newport Beach and Irvine.
Because of the close proximity of the prostate to the rectum, prostate
radiation therapy typically results in some radiation hitting the rectum,
which can sometimes cause side effects. The SpaceOAR System creates space
by temporarily pushing the rectum away from the prostate and the high
dose area. Placed through a small needle, the hydrogel is administered
as a liquid, but quickly solidifies into a soft gel that expands the space
between the prostate and rectum. The hydrogel spacer maintains this space
until radiation therapy is complete. The spacer then liquefies and is
absorbed and cleared from the body in the patient’s urine. This
is a significant advancement considering that the most common side effect
of radiation therapy is related to proctitis. By creating space between
the prostate and rectum, SpaceOAR hydrogel reduces rectum radiation injury,
and the resulting long-term complications such as diarrhea, bleeding and pain.
Stereotactic Radiation Therapy (SRT) / Stereotactic Body Radiation Therapy (SBRT)
Stereotactic Radiation Therapy (SRT) is an intermediate technique, with
many of the characteristics of both Stereotactic Radiosurgery (SRS) and
Image-Guided Intensity-Modulated Radiation Therapy (IG-IMRT). When applied
outside of the brain, this technique is often called Stereotactic Body
Radiation Therapy (SBRT). SRT uses doses higher than standard doses with
conventional radiation therapy, but lower that SRS. The length of treatment
is also intermediate - typically given in five daily dose fractions.
At Hoag, SRT and SBRT are delivered with the Tomotherapy unit. Tomotherapy
is especially suited for SRT/SBRT because of the precise nature of helical
IMRT, and the capability to take 3D images for treatment verification.
When delivered to the brain, SRT uses a thermoplastic immobilization mask
that is molded to the patient's head. In contrast to the rigid head frame
of SRS, this mask is applied non-invasively. When delivered to the body
(SBRT), the patient is placed in a molded cradle, and wrapped with plastic
covering. Suction is applied to hold the patient in a stable position.
In both circumstances, 3D imaging is performed prior to each treatment
to verify correct positioning. SRT is used to treat benign and malignant
tumors of the brain, such as meningiomas, pituitary adenomas, acoustic
neuromas, large metastases (spread of cancer from other sites in the body),
optic tumors, and gliomas (anaplasticastrocytoma, glioblastomamultiforme).
SBRT is used to treat selected tumors in the body, such as spinal lesions,
liver metastases and lung metastases.
Hoag has a distinct advantage with active SRT/SBRT and SRS programs in
the same facility. Our weekly multidisciplinary Neuro-Oncology Tumor Board
specialists are therefore able to recommend and carry out optimal treatment
regimens within this fully integrated facility assuring the patients the
best possible treatment options.
Stereotactic Radiosurgery (SRS)
Stereotactic Radiosurgery (SRS) is a technique that delivers a single large
dose of radiation to a precisely determined target. It is an alternative
or adjunct to neurosurgery or conventional radiation.
The term stereotactic refers to a localizing system that uses a rigid
head frame attached to the patient's skull for precision set-up. Radiosurgery
refers to the highly focused beams of radiation that can be used for the
same purposes as conventional surgery, but without ever cutting or opening
up the patient. The only invasive portion of the procedure is attaching
the head frame to the skull, which requires only local numbing medications
and light sedation for comfort. There is virtually no recovery time, and
the patients go home in the afternoon of their treatment day. In addition,
the highly focused beams deliver a larger single dose than possible with
other radiation techniques. This large single dose has been found to be
more effective in treating certain tumors and conditions.
SRS is most commonly used to treat benign and malignant tumors of the
brain, such as brain metastases (cancer that has spread from other parts
of the body), meningiomas, pituitary adenomas, acoustic schwannomas, arteriovenous
malformations (AVMs), and malignant gliomas (anaplasticastrocytomas and
glioblastomamultiforme). SRS is also used to treat some neurologic conditions
such as trigeminal neuroalgia, epilepsy, and Parkinson's Disease.
At Hoag, SRS is performed with the Gamma Knife Perfexion, a highly advanced
and specialized radiation machine. SRS performed on the Gamma Knife is
also referred to as Gamma Knife Radiosurgery (GKRS).
Hoag has a distinct advantage with active SRT/SBRT and SRS programs in
the same facility. Our weekly multidisciplinary Neuro-Oncology Tumor Board
specialists are therefore able to recommend and carry out optimal treatment
regimens within this fully integrated facility assuring the patients the
best possible treatment options.
For more information, please visit Hoag Gamma Knife Center.
Superficial Radiation Therapy (Skin Treatment)
Radiation therapy is an extremely effective method of treating (non-melanoma)
skin cancer. Non-melanoma skin cancer includes cell type diagnosis of
basal cell and squamous cell. Superficial (on the skin) treatment for
skin cancer (non-melanoma) requires the use of a special machine that
will treat the skin but not the underlying tissues. Hoag houses just such
a machine. Radiation treatment to skin cancer allows the patient to avoid
the alternative option of surgery, which often results in scarring.
Although not much information is shared about this effective treatment
option, Hoag's experienced radiation oncology team performs more than
1,100 treatments each year.
TomoTherapy®
Tomotherapy® is a specialized treatment machine specificallydesigned
for Image-Guided Intensity-Modulated Radiation Therapy (IG-IMRT). The
concept of treating cancer with radiation is a simple one: irradiate the
cancer cells and they die. The challenge, therefore, lies in sparing the
healthy tissue surrounding the tumor - that's precisely what Tomotherapy
is all about.
Tomotherapy achieves the ability to deliver maximum radiation dose to a
target volume while sparing the surrounding healthy tissue by utilizing
a CT scanner for daily image guidance to ensure proper patient set-up
based on the internal anatomy. The machine's superior ability to modulate
the intensity of the radiation to conform around the target volume also
significantly decreases the dose to healthy tissue.
"The breakthrough technology that makes Tomotherapy unique is that it combines
the capabilities of a standard CT scanner with those of a radiation therapy
linear accelerator," explains Radiation Oncologist Peter Chen, M.D. "Like
a standard CT scanner, the Tomotherapy source spirals around the patient
like a corkscrew, enabling it to take three-dimensional pictures that
help doctors to precisely localize treatments. However, instead of the
imaging x-rays from a standard CT scanner, the Tomotherapy source, like
a linear accelerator, emits cancer-killing megavoltage photons. With both
these capabilities in hand, doctors are able to treat patients with unprecedented
accuracy."
Traditionally, radiation therapy treated a tumor by focusing relatively
large beams of radiation from two to six directions. In contrast, Tomotherapy
uses hundreds of pencil beams of radiation, rotating in a spiral around
the tumor and hitting it from all directions. As the beam is rotating,
the intensity of the radiation is varied, allowing the radiation oncologist
to deliver the radiation with incredible precision. In addition, the radiation
can be sculpted to fit the shape of the patient's tumor, again providing
more precise and effective treatment.
Another radiation treatment challenge lies in the movement of tumors -
sometimes as little as a millimeter. The Tomotherapy system can provide
3D CT imaging immediately prior to treatment to verify the location of
the patient's tumor. By confirming the precise tumor location, the accuracy
of the delivery is greatly increased.
Tomotherapy uses 3D Conformal Radiation Therapy (3DCRT) and IMRT technologies,
with the addition of helical delivery and 3D imaging (IG-IMRT) for treatment
verification.
Learn how Tomotherapy is used in
breast cancer treatment.
VMAT (Volumetric Arc Therapy)
VMAT or Volumetric Arc Therapy is an advanced radiation therapy technique
that delivers high radiation doses precisely to the tumor while reducing
dose to surrounding normal tissues and organs. The radiation is delivered
as the machine sweeps in single or multiple arcs around the patient while
varying a number of treatment machine parameters. This advanced technique
can lead to significantly reduced treatment times resulting in shorter
times on the treatment table and therefore increased patient comfort.
Hoag’s Elekta Infinity is a state-of-the-art computer controlled
linear accelerator with VMAT capabilities and the latest in 3D image guidance
for increased accuracy. Equipped with both conebeam CT and megavoltage
imaging the Infinity can insure precise daily patient positioning and
tumor targeting. Featuring an advanced MLC (multileaf collimator) and
fully integrated with the Cancer Institute’s Mosaiq Oncology Management
system the Elekta Infinity with VMAT represents one of latest advances
in treatment technology.