Developments in technology over the last few decades have also significantly improved treatment options in the area of radiotherapy planning and therapy.

In the past, radiotherapy was planned using a special X-ray machine ("simulator") based on the bony anatomy. A few radiation fields were aimed at the planning volume, with the areas of the body close to the planning volume receiving a higher dose. In addition, a larger safety margin was required around the body area to be irradiated due to limited possibilities for checking patient positioning, which ultimately led to higher side effect rates.

Nowadays, all radiotherapy is planned three-dimensionally on the basis of computer tomography ("planning CT"). The areas of the body to be irradiated are defined taking into account the radiological and nuclear medicine diagnostics (superimposition of planning CT with contrast agent CT, MRI, PET-CT) and the patient's individual anatomy. In addition, the organs to be spared can be determined in the CT. The medical physics experts can then precisely describe the dose distribution after the physical radiotherapy planning and verify it using measurement phantoms before the radiotherapy plan is applied to the patient.
Another significant improvement is the verification of the current body position immediately before the actual radiotherapy ("image-guided radiotherapy", "IGRT"). With the help of X-ray images (CT / MV images, CBCT), the patient's current body position can be checked with millimetre precision and corrected if necessary.

Modern techniques have contributed to the fact that the therapy is generally very well tolerated and that the frequency and severity of both acute and late side effects have decreased overall.

At the Medical Care Centre of Ulm University, outpatient treatments can be carried out for...

... malignant diseases (selection):

• Breast carcinoma
• Prostate carcinoma
• Rectal carcinoma (oral radiochemotherapy if necessary)
• Brain tumours (oral radiochemotherapy if necessary)
• Brain metastases
• Bone metastases
• Skin tumours

... benign diseases (selection):

• Heel spur (plantar fasciitis)
• Achillodynia
• Arthrosis of the shoulder, hip, knee, hands and feet
• Dupuytren's disease
• Ledderhose disease
• Graves' disease
• Periarticular calcifications of the hip
• Male gynaecomastia
• Meningiomas

In principle, several types of radiation can be used for medical purposes (fast electrons, gamma / photon, neutron, proton and ion radiation). These differ in their physical behaviour in human tissue (penetration depth, course of interaction at molecular level). The MVZ mainly uses photons, which are generated by a modern linear accelerator.

While numerous effects of ionising radiation in the body can be described (radical formation, alteration of biomolecules, etc.), the decisive effect in the treatment of tumours is the alteration of the genetic material of the cell, the DNA. Here, single and double-strand breaks are produced, which can also be repaired by the tissue. Healthy cells can usually repair these effects reliably, while tumour cells lose the ability to divide indefinitely or die.

In benign diseases such as arthrosis, there is an inflammatory change in an area of the body (joint capsules, tendons, etc.) that is sometimes poorly supplied with blood. As a result, drug therapies may not have the desired effect. Radiotherapy for benign diseases is also intended to have an anti-inflammatory effect. Therefore, low doses (e.g. 6 irradiations with 0.5Gy) are used to suppress the cell interactions that play a role in the inflammation of the tissue. After all, in contrast to tumour therapy, no cells are to be killed. The desired long-term pain relief usually only sets in after 6-12 weeks.

You will receive an appointment from your attending doctor for the first consultation in our outpatient clinic. If possible, you should collect all available findings beforehand and bring them with you to the initial consultation. External imaging (CTs, MRIs, PET/CTs) on CD are particularly important. The electronic form is important for later use in radiotherapy planning.
You are welcome to provide us with the documents and CDs in advance.

First presentation
A patient file is created at the first appointment in the outpatient clinic. The findings and medical reports as well as the electronic imaging (X-rays, CTs, MRIs...) are viewed and assessed by the outpatient doctor. If necessary, further diagnostic measures will also be organised for you.
A preliminary treatment plan can then be drawn up, which will be discussed with you in a detailed information session. Standardised information sheets will be completed with relevant information about your individual situation. You will receive a copy of these for your records.
Finally, you will receive the dates for the planning CT and the first radiotherapy treatment.

PlanningCT
The planning CT is used to electronically record your body anatomy for subsequent radiotherapy planning. You will be positioned on the CT couch in such a way that the conditions are optimised for the subsequent radiation treatment.
If necessary, positioning utensils are used and radiation masks are made. These are necessary for reproducible positioning during the subsequent treatment.
Initial markings define an important reference point for the radiotherapy plan on the body. Due to its significance, this may be immortalised with small dots on the skin (tattoo dots). In addition, special technical properties of the CT are coordinated with the radiotherapy planning software.
Therefore, we cannot use just any CT for radiotherapy planning.

Contouring
The doctor now draws the planning volume to be treated layer by layer in the planning CT, taking into account the previous diagnostics. Organs that are to be spared during treatment can also be defined three-dimensionally.
The planning volume is demonstrated in a joint discussion and approved for further use.

Physical radiotherapy planning
The radiotherapy plan is drawn up by medical physics experts on the basis of the doctor's prescription. Either individual radiation fields are defined with the corresponding energy and the appropriate spatial dimensions so that the planning volume receives the required dose. The dose calculation itself is performed by the software and superimposed on the planning CT with dose lines ("isodoses") or transparent colours ("colour wash"). An important tool for assessing the treatment plan is a graphical representation of how much of the planning volume receives which dose ("dose-volume histogram"). This allows essential dose limits for different organs to be defined and assessed.
The radiotherapy plans are approved by the specialist for the next steps.
The plans are then checked on a measuring phantom, if necessary, before they can be used on the patient.

First radiation treatment ("new setting")
During the first radiotherapy session, you will be positioned on the treatment couch of the linear accelerator in exactly the same way as for the planning CT. After checking the correct positioning using imaging, additional markings are applied to the skin (or the radiation mask). These markings are not covered with plasters due to the risk of developing allergies.
These markings are very important for positioning during the course of therapy. You should therefore pay particular attention to the markings. You will be given appropriate recommendations during your initial consultation.

During radiotherapy...
... you will receive an interim consultation with the MVZ doctor once a week or as required.
If you have any questions about your treatment or its side effects, you are welcome to bring them up during the consultation. If necessary, you can apply for follow-up treatment in cooperation with the social counselling service.

Aftercare
As after any medical treatment, radio-oncological aftercare is required. As a rule, we carry this out after 6 weeks, 6 months and then at annual intervals. You should also visit your specialist (gynaecologist, urologist, oncologist, etc.), usually at three-monthly intervals. If necessary, he or she will also arrange for equipment examinations (ultrasound, CT, MRI...).

Acute reactions to radiotherapy are typically caused by inflammation and affect the areas of the body in the radiotherapy field. In the case of radiotherapy to the breast, for example, discrete to slight reddening of the skin and a feeling of oedematous swelling can occur, which can be managed very well with conservative measures such as skin creams and cooling. More severe irritation is usually rare. During the initial consultation, the attending physician will discuss with you the individual reactions you can expect and explain what measures may be necessary.
Late reactions are usually characterised by scarring of the irradiated tissue and only occur occasionally with modern radiotherapy. These reactions will also be discussed with you in detail during the initial consultation with the MVZ doctor, taking your individual situation into account.

• IGRT ("image guided radiotherapy")
• IMRT ("intensity modulated radiotherapy")
• 3D planning
• Planning CT
• Planning volume
• Organs at risk
• Dose-volume histogram
• PV images (KV / MV)
• Cone-beam CT
• Isodoses
• Fractionation