Radiation Oncology

The Department of Radiation Oncology is proud to be part of Columbia Cancer and the Herbert Irving Comprehensive Cancer Center, one of the few centers to be internationally recognized by the National Cancer Institute. Our NCI-designated partners have worked together to strengthen one another’s programs and research endeavors to new levels. These collaborations allow us to establish best practices and cutting edge therapies and to provide outstanding patient care.

Our Approach

We now have the ability to tailor treatment to the individual, taking into account any changes in the tumor or the patient’s own anatomy. These approaches enable us to reduce radiation exposure and more precisely target the treatment area without affecting healthy tissue.

Our patients also benefit from a highly coordinated multidisciplinary approach to patient care. Columbia’s leading experts in radiation and oncology collaborate with renowned surgeons and medical oncologists to provide guidance and support at every step of the treatment process. Our goal is to deliver the very latest therapies in an environment conducive to optimal healing.

Conditions We Treat

Treatments

Our specially trained board-certified radiation oncologists are skilled in a wide range of standard and emerging treatments including: 

3D Conformal Radiotherapy

The goal of three-dimensional conformal radiotherapy (3D-CRT) is to deliver a dose that conforms to the shape of the tumors, while sparing surrounding healthy tissue. This approach uses 3D images in the treatment planning process and is (often more precise) than conventional radiotherapy. With this approach, CT and/or MRI images are used to define the areas of treatment and to distinguish the tumor from normal structures. With this data, the physician can develop a complex treatment plans that delivers most concentrated dose of radiation within the confines of the tumor. 3D-CRT is used to treat tumors that in the past might have been considered too close to vital organs and structures for radiation therapy.

4D CT Treatment Planning and Delivery

The explicit inclusion of the temporal changes in anatomy during imaging, planning and delivery of radiotherapy.  Completing 4D CT Imaging is the acquisition of a sequence of cat scan imaging over consecutive phases of a breathing cycle, i.e. inspiration, expiration, normal breathing. This imaging technique allows for the physics team to complete a 4D Treatment plan designing treatment on CT image sets obtained for each phase of the breathing cycle. Utilizing the 4D Treatment plan allows the therapy team to deliver the radiation dose throughout the breathing cycle. 

Adaptive Radiation Therapy (ART)

Adaptive Radiation Therapy (ART) allows physicians to continually modify a patient’s treatment plan based on new measurements of tumor size or the tumor cavity, and any relevant changes in the patient’s own anatomy.  Because adaptive radiation therapy systematically monitors these and other important variables, our experts can make significant adjustments in the field of treatment, and in dosage of radiation given, early on. This approach allows us to customize the therapy to the individual patient, and target radiation therapy with greater accuracy and precision. 

Brachytherapy

Brachytherapy is a radiation therapy modality that allows the escalation of radiation dose while sparing normal tissues. Increased radiation dose has been shown in many situations to provide improved results by improving local tumor control. Brachytherapy involves the placement of radioactive sources ("seeds" or wires) either in tumors (interstitial implants) or near tumors (intracavitary therapy and mold therapy). The radiation is emitted outward, unlike external beam radiotherapy, where radiation must transverse normal tissue in order to reach the tumor. The word "brachytherapy" means "short therapy", appropriately implying that the radiation is limited to short distances. This results in decreased toxicity and/or allows the escalation of radiation dose. Brachytherapy can be used intraoperatively in situations where surgery is not possible or not optimal or in situations where prior dose-limiting external radiotherapy has already been given. Combined approaches of surgery and brachytherapy can often improve the results of surgery alone in a variety of malignancies.

At Columbia University Irving Medical Center, brachytherapy has successfully been used to treat a variety of tumors, including tumors of the cervix, esophagus, biliary tract, pancreas, head and neck, soft tissue sarcomas, and prostate cancer. Efforts are currently under way to optimize the use of brachytherapy by altering dose rate and fractionation. High dose rate, low dose rate, and pulsed dose rate techniques are being explored. Novel approaches combining chemotherapy with external beam radiotherapy and brachytherapy may improve the results in treatment of a variety of tumors.

Thoracic
Endobronchial brachytherapy is an innovative form of radiation therapy that uses high-dose rate (HDR) brachytherapy to destroy tumors in the lungs or throat, via the bronchial tubes.

Gynecological
Radiation can also be delivered with lose dose rate (LDR) or high dose rate (HDR ulitizing a vaginal cylinder applicator or with the tandem and ovoids applicator. You and your doctor will determine which type of radiation and applicator are right for you.

Prostate
Radioactive seed implantation is when tiny radioactive particles no larger than a grain of rice are implanted directly into the treatment cavity. These seeds are implanted directly into, or in very close proxcimity, to the tumor which allows them to deliver high doses of radiation to the tumor without affecting the normal healthy tissues around it.

IORT
Intraoperative Radiation Therapy (IORT) delivers a single highly target dose of radiation directly to the lumpectomy cavity during breast surgery---immediately after a tumor is removed. Focusing the radiation in that cavity rather than applying radiation to the whole breast is as effective as whole breast radiation, according to research comparing the two methods. Watch NBC and ABC news reports on this innovative therapy here and here.

Eye Plaque
Plaque brachytherapy is the most widely used treatment for choroidal melanoma and delivers a highly concentrated radiation dose to the tumor (with relatively less radiation to surrounding healthy tissues). The radioactive plaque can also be called a “radiation implant” or “radioactive source.”

Yttrium 90
Working with the Interventional Radiologist Y-90 utilizes thousands of radioactive beads injected directly safely into the arteries that supply blood to the tumor. These radioactive beads are made of either plastic or glass known as either Theraspheres or SIR-Spheres.

CTVision

A novel imaging technology called CTVision helps to reduce radiation to critical body structures. The CT scanner pivots around the patient, taking a series of pictures that pinpoint the exact location to receive radiation therapy. This technique is also called “CT on Rails.” This approach results in more precise positioning of the patient and the ability for more precise targeting of the tumor. This is one of many new techniques that allow physicians to reduce the amount of radiation delivered during therapy.

External Beam Radiation Therapy

External Beam Radiation Therapy involves a series of daily outpatient treatments to accurately deliver radiation to the breast. Painless radiation treatments are delivered in a series of daily sessions. Each treatment will last less than 30 minutes, Monday through Friday, for five to seven weeks. The usual course of radiation treats only the breast, although treatment of the lymph nodes around the collarbone or the underarm area is sometimes needed.

Gamma Knife Radiosurgery

The Gamma Knife is a safe, non-invasive device for treating deep–seated brain tumors and Arteriovenous Malformations (AVM's). With this emerging technology, many conditions, including those that were once considered inoperable, can now be treated without the need for an incision and with little or no pain.

The Gamma Knife is not a knife as its name implies. It is a highly sophisticated system that delivers up to 201 beams of gamma radiation, with pinpoint accuracy,  to an abnormality within the brain. When concentrated, the rays provide enough radiation to treat the diseased area effectively. Yet the low intensity of each single beam ensures the safety of the surrounding healthy brain tissue.

The Procedure

On the day of treatment, the patient is fitted into a metal frame, called a stereotactic headframe.  Open on all sides, it allows physicians to precisely target the abnormality throughout the several procedures. First patient’s brain is screened with images taken with by MRI (Magnetic Resonance Imaging), a CT scan or angiogram. This determines the size and position of the tumor or AVM.

Once the imaging studies are completed, physicians use a computer program to help plan the course of treatment.

The target area of the brain and the appropriate radiation dosage are quickly established. Now ready for the Gamma Knife, the patient lies down. The head frame is now positioned inside a large metal helmet, called a collimator. Next, the patient slides into the Gamma Knife's sphere, which contains the source of radiation.  The collimator then directs radiation to the pre-determined points in the patient's brain.

Treatment usually consists of a series of exposures, each lasting approximately 10 minutes. Patients experience little or no discomfort, and most are able to to home the day of the procedure.

Gamma Knife Benefits

With the Gamma Knife, post-treatment complications are greatly reduced when compared to open surgery (or other types of radiation?). Further, areas of the brain for which other therapies are ineffective can be successfully treated. The Gamma Knife's precision and safety make it a highly appropriate choice for both pediatric and adult patients.

The range of diseases effectively treated by the Gamma Knife includes:

  • Vascular lesions such as arteriovenous malformations (AVMs)
  • Acoustic neuroma
  • Meningioma
  • Pituitary Tumors
  • Pineal Tumors
  • Metastases
  • Glial and astrocytic tumors
  • Skull base tumors
  • Other benign and malignant tumors
  • Trigeminal neuralgia

The use of the Gamma Knife continues to expand, as a result of ongoing research and development.

Learn More About Gamma Knife Radiosurgery From Our Columbia Neurosurgeons

Hypofractionated Breast Radiotherapy

Hypofractionated Breast Radiotherapy is a revolutionary breakthrough regarding breast cancer treatment. This technique reduces treatment time by half—3 weeks of treatment instead of the traditional 6 week course.

Image Guided Radiation Therapy (IGRT)

Image Guided Radiation Therapy (IGRT) allows physicians to take a series of images during radiation treatment.  These images can help improve the accuracy of radiation therapy in selected patients.

Tumors that move during the breathing cycle, such as those within the lung or liver, can present a challenge for conventional radiation treatment–as moving targets, they are harder to "hit" with a focused beam of radiation. In order to properly treat these tumors, a wider field must be targeted.

Respiratory gating is a technology that allows the radiation oncologist to monitor the patient's breathing pattern during the treatment. The radiation bean can then be turned on only during a specific segment of the breathing cycle.  With this approach, the effects of respiratory motion can be significantly reduced, or even eliminated. This allows for more accurate targeting of the tumor, and may also reduce the amount of radiation received by the surrounding healthy tissue.

Intensity-modulated radiation therapy (IMRT)

Intensity-modulated radiation therapy (IMRT) is an advanced form of three-dimensional conformal radiotherapy (3DCRT).  In addition to using multiple shaped portals from which the radiation beams emanate, the intensity of the beams within each portal is spatially modulated using sophisticated software and hardware. This enables an optimized dose distribution to be delivered to the three-dimensional tumor volume while maintaining constraints of avoiding close or overlapping normal structures. IMRT is often used for the treatment of tumors that are in close proximity to normal organs that are more sensitive to radiation.  For example, IMRT is often used in the treatment of prostate cancer to achieve high tumor control with significantly reduced rectal toxicity.

Intraoperative Radiation Therapy (IORT)

Intraoperative Radiation Therapy (IORT) delivers a single highly target dose of radiation directly to the lumpectomy cavity during breast surgery—immediately after a tumor is removed. Focusing the radiation in that cavity rather than applying radiation to the whole breast is as effective as whole breast radiation, according to research comparing the two methods. Watch NBC and ABC news reports on this innovative therapy.

Linear Accelerator-Based Stereotactic Radiosurgery

Provides radiation in the form of a single highly focused beam applied in multiple sweeps around the brain lesion, and is suitable for larger tumors. This method also permits multiple smaller-dose, or fractionated radiotherapy, which offers advantages for some patients.

Partial Breast Irradiation

Doctors are studying ways to deliver radiation to only the affected portion the breast. Available in a few clinics for a very select group of patients, these techniques are used after a lumpectomy to deliver radiation to the tumor site rather than the entire breast.

Breast brachytherapy involves placing flexible plastic tubes called catheters or a balloon into the breast. Over one to five days, the catheters or the balloon are connected to a brachytherapy machine so high doses of radiation can treat the nearby breast tissue.

Other partial breast treatments include 3-D conformal Irradiation and Intra-operative Radiation Therapy (IORT) delivered in the course of surgery (lumpectomy).

Stereotactic Body Radiotherapy (SBRT)

Precise delivery of radiation to a tumor while sparing normal surrounding tissues. This technique achieves a higher dose than what could be given with conventional techniques.

Both SRS and SBRT can be used to treat pediatric cancers, as well as those that occur in adults.

Stereotactic Radiosurgery (SRS)

Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Stereotactic radiosurgery are new procedures that allow physicians to deliver high doses of radiation to the tumor site while sparing healthy issues.

SRS is not an actual surgery—it is the ability to deliver radiation to the target site from a variety of different angles, based on 3D imaging. In some cases,image-guided radiation therapy (IGRT) may be used to pinpoint the location of the tumor before and/or during the radiation treatment.

The advantages over conventional radiation therapy are as follows. SRS can nr used to treat extremely small tumors or those located in hard-to-reach places. The treatment time is significantly shorter. And while the therapy can often be completed in a single day, radiation oncologist may recommend multiple treatments, depending upon the size of the tumor.

Stereotactic radiosurgery is generally used to treat brain and spinal cancers.

Stereotactic body radiation therapy (SBRT) offers the same benefits as stereotactic radiosurgery and is used to treat a wide variety of cancers.

Total Body Irradiation (TBI)

Total body irradiation (TBI) is used at Columbia University Medical Center as part of the conditioning regimen prior to allogeneic (from a matched donor) bone marrow transplantation for leukemias and lymphomas.

Often allogeneic stem cells (ie.) are used for the reconstitution of the immune system after high-dose therapy. Allogeneic cells (from a brother/sister or from an unrelated HLA-matched donor) provide a therapeutic benefit since their immune function plays a role in fighting the patient’s cancer. Total body irradiation aids in the acceptance, of these foreign immune cells.

Better supportive care, refinements and improvements in total body irradiation technique and chemotherapy regimens, and new insights into immune cell therapeutics, all contribute to the more effective management of these patients.

Volumetric Arc Therapy (VMAT) - RapidArc

Volumetric Arc Therapy (VMAT) or RapidArc is the most advanced form of Intensity modulated radiotherapy (IMRT) which allows for precise delivery of the radiation beam in a 360-degree rotation of the grantry. VMAT allows for treatment times from 2 minutes up to 10 minutes; much better than conventional IMRT treatment plans that allow for multiple treatment fields in which the gantry stops multiple times delivering separate radiation beams. VMAT utilizes special software and an advanced linear accelerator to deliver these treatments daily. This treatment is more comfortable for patients because they spend less time in their designed treatment positions. This allows patients to be able to have access to daily radiation treatment and be back to their normal routine in a quick amount of time.

What to Expect

Before Treatment

Consultation

If you are considering radiation therapy, you must first schedule a visit with a radiation oncologist to see if radiation therapy is right for you. During your initial visit, the doctor will evaluate your need for radiation therapy and its likely results. This includes reviewing your current medical problems, past medical history, past surgical history, family history, medications, allergies and lifestyle. The doctor will also perform a physical examination to assess the extent of your disease and judge your general physical condition. Depending on where your radiation oncologist practices, you may also be seen by a medical student, a resident (radiation oncologist in training), a nurse practitioner, a physician assistant or a nurse.

After reviewing your medical tests, including CT scans, MR scans and positron emission tomography scans (PET scans), and completing a thorough examination, your radiation oncologist will fully discuss with you the potential benefits and risks of radiation therapy and answer your questions.

Simulation and Treatment Planning

To be most effective, radiation therapy must be aimed precisely at the same target or targets each and every time treatment is given. The process of measuring your anatomy and marking your skin to help your team direct the beams of radiation safely and exactly to their intended locations is called simulation.

During simulation, your radiation oncologist and radiation therapist place you on the simulation machine in the exact position you will be in during the actual treatment. Your radiation therapist, under your doctor's supervision, then marks the area to be treated directly on your skin or on immobilization devices.

Immobilization devices are molds, casts, headrests or other devices that are constructed and placed on a certain part of your body to help you remain in the same position during the entire treatment. The radiation therapist marks your skin and/or the immobilization devices either with a bright, temporary paint or a set of small permanent tattoos.

Your radiation oncologist may request that special blocks or shields be made for you. These blocks or shields are put in the external beam therapy machine before each of your treatments and are used to shape the radiation to your tumor and keep the rays from hitting normal tissue. Some treatment machines have built-in blocks or shutters called multileaf collimators, which also help shape the radiation.

Although simulation is typically only one session, your physician may schedule additional sessions depending on the type of cancer you have and the type of radiation therapy that is being used.

After simulation, your radiation oncologist and other members of the treatment team review the information they obtained during simulation along with your previous medical tests to develop a treatment plan. Often, a special treatment planning CT scan is done to help with the simulation and treatment planning. This CT scan is in addition to your diagnostic CT scan. Frequently, sophisticated treatment-planning computer software is used to help design the best possible treatment plan. After reviewing all of this information, your doctor writes a prescription that outlines the exact course of your radiation therapy treatment.

During Treatment

Treatment Administration

External beam radiation therapy is administered differently from brachytherapy. You may receive one or both of these treatments. The following sections describe what you may experience during treatment administration.

External Beam Radiation Therapy Treatments

When you undergo external beam radiation therapy treatment, each session is painless, like getting an X-ray. The radiation is directed at your tumor from a machine located outside of your body. One of the benefits of radiation therapy is that it is usually given as a series of outpatient treatments and you may not need to miss work or experience the type of recuperation period that can follow other treatments.

Treatments are usually scheduled five days a week, every day except Saturday and Sunday, and continue for three to 10 weeks. Some patients receive hyperfractionated radiation therapy, in which radiation treatments are given more than once a day. Other times, only one or a few treatments are required, such as for the treatment of cancer that has spread to the bone. This is called hypofractionated radiation therapy. The number of radiation treatments you will need depends on the size, location and type of cancer you have, your general health and other medical treatments you may be receiving.

The radiation therapist will administer your external beam treatment following your radiation oncologist's instructions. It will take roughly five to 15 minutes for you to be positioned for treatment and for the equipment to be set up. If an immobilization device was made during simulation, it will be used during every treatment to make sure that you are in the exact same position every day.

Once you are positioned correctly, the therapist will leave the room and go into an adjoining control room to closely monitor you on a television screen while administering the radiation. There is a microphone in the treatment room so you can always talk with the therapist if you have any concerns. The machine can be stopped at any time if you are feeling ill or uncomfortable.

The radiation therapist may move the treatment machine and treatment table to target the radiation beam to the exact area of the tumor. The machine might make noises during treatment that sound like clicking or whirring. These noises are nothing to be afraid of, and the radiation therapist is in complete control of the machine at all times.

The radiation therapy team carefully aims the radiation to decrease the dose to the normal tissues surrounding the tumor. Still, radiation will affect some healthy cells. The time in between daily treatments allows your healthy cells to repair much of the radiation damage. Most patients are treated on an outpatient basis, and many can continue with normal daily activities.

Sometimes a course of treatment is interrupted for a day or more. This may happen if you develop side effects that require a break in treatment. These missed treatments may be made up by adding treatments at the end. Try to arrive on time and not miss any of your appointments.

Your radiation oncologist monitors your daily treatment and may alter your radiation dose based on these observations. Also, your doctor may order blood tests, X-ray examinations and other tests to see how your body is responding to treatment. If the tumor shrinks, another simulation may be done. This allows your radiation oncologist to change the treatment to destroy the rest of the tumor and spare even more normal tissue.

Brachytherapy Treatments

Brachytherapy, also called internal radiation or seed implants, is the placement of radioactive sources in or just next to a tumor. The radioactive sources may be left in place permanently or only temporarily, depending upon your cancer. To position the sources accurately, special catheters or applicators are used.

There are two main types of brachytherapy: intracavity treatment and interstitial treatment. With intracavity treatment, the radioactive sources are put into a space near where the tumor is located, such as the cervix, the vagina or the windpipe. With interstitial treatment, the radioactive sources are put directly into the tissues, such as the prostate.

Often these procedures require anesthesia and brief hospitalization. Patients with permanent implants may have a few restrictions at first and then can quickly return to their normal activities. Temporary implants are left inside of your body for several hours or days. While the sources are in place, you will stay in a private room. Doctors, nurses and other medical staff will continue to take care of you, but they will need to take special precautions to limit their exposure to radiation.

Devices called high dose rate remote afterloading machines allow radiation oncologists to complete brachytherapy quickly, in about 10 to 20 minutes. Powerful radioactive sources travel through small tubes called catheters to the tumor for the amount of time prescribed by your radiation oncologist. You may be able to go home shortly after the procedure. Depending on the area treated, you may receive several treatments over a number of days or weeks.

Most patients feel little discomfort during brachytherapy. If the radioactive source is held in place with an applicator, you may feel discomfort from the applicator. There are medications that can help this. If you feel weak or queasy from the anesthesia, your radiation oncologist can give you medication to make you feel better.

Weekly Status Checks

During radiation therapy, your radiation oncologist and nurse will see you regularly to follow your progress, evaluate whether you are having any side effects, recommend treatments for those side effects (such as medication or diet changes) and address any concerns you may have. As treatment progresses, your doctor may make changes in the schedule or treatment plan depending on your response or reaction to the therapy.

Your radiation therapy team may gather on a regular basis with other healthcare professionals to review your case to ensure your treatment is proceeding as planned. During this session, all the members of the team discuss your progress as well as any concerns.

Weekly Beam Films

During treatment, your treatment team will routinely use the treatment machines to take special X-rays called beam or port films. Your treatment team routinely reviews these films to be sure that the treatment beams remain precisely aimed at the proper target. These X-rays are not used to evaluate your tumor.

After Treatment

Follow-Up

After treatment is completed, follow-up appointments will be scheduled so that your radiation oncologist can make sure your recovery is proceeding normally and can continue to monitor your health status. Your radiation oncologist may also order additional diagnostic tests. Reports on your treatment can be sent to your other doctors.

As time goes on, the frequency of your visits will decrease. However, you should know that your radiation oncology team will always be available should you need to speak to someone about your treatment.

*Interpreter Services are available at Columbia University Irving Medical Center