 Good morning everyone. I hope you are fine and you have a very nice Breakfast, so I think we can start yes first of all I also Thank my colleague Professor Padobani to ask me to come here. These are beautiful places in ICTP It is very prominent very famous, you know all over the world It is dream every scientist to be one times in ICTP Campus and you are here and they have many many many many activities not only medical physics Professor Padobani and his friend Bhattuchi they introduced medical physics. We are lucky enough that we have medical physics in ICTP I ask him maybe the capital of medical physics all over the world and you please Develop it thank Thank you very much. Yes The professor my colleagues and gunter introduced me. I am long time here like you From the developing country and I have a experience in Germany Little bit in Europe and of course in developing country in our society of medical physics in Germany We have a tax group. It's called medical physics in developing country. So we support not only in Bangladesh I was in Africa even in South America. So all over the world points anybody want to arrange that Something similar in your country then maybe in European level We can visit them on many many people. They want to do that. So we have a very short time I must also Maintain my time. So you have learnt many things in last three days I think you know from their propation also the medical physics medical physics is a new subject I think in the new subject not so new but in developing country new subject We are fighting against cancer, but at the same time we are fighting for our positions our salary So when everything we are fighting parallel So we are a very we should be a strong foot in the in the earth and try to find Not only in the hospital, but also in the government level. So you have a huge tax to do So your subject is not so easy, but it is challenging. I hope we are strong enough to do All the things parallel so that actually at the end there is a good help for the disease patient cancer patient. So here three dimensional conformal therapy. It is actually Important tools I know from many countries even in Germany most of the hospital they do the conformal conformal radiotherapy and in some places Also I am RT in German even They do not like to introduce I am RT because is a many problems there even the Insurance do not pay for that did not pay for the I am RT, but now they pay also for I am RT So I am RT is actually increasing every day today So Yeah, I think you have seen this from IA everybody. I do not actually explain the tax of medical physics Medical physicist you know more or less everybody it started from the construction of the bunker up to the up to the Treatment of the patient. Yes, this is all the tax for you. What I want to mention here actually Here you see the these are the partners in the hospital. Actually you have radiation oncologist and technicians some countries like America. They are telling radiation therapies They are technician so the three person in a group and team and it is your duty to work together Only when you work together, then you have a good quality assurance Yeah They feel sees the work when alone they have some quality control, but not the quality assurance Yeah, not the outcome of the passion. So please do a very close contact with them Yes, not only sitting your dark room with some Computer treatment planning, but you always go to the positioning and other cases where you have a close contact the Hospital authority especially the medical doctor knows every day passion passion Added in the meeting not somewhere in dosimetry summer treatment plan Nobody knows what you're doing and you are afraid because nobody knows or nobody respect you But they do not actually know what you are doing. That's why the patient passion Close is very important for you. Yes so this is a teamwork and Teamwork is very important. I'm telling the full quality assurance. This is all to the chain, you know From the professor Hartman what I want to say here actually the 3d amazing here started Everything there you have many many modalities. So we can actually Find the tumor very well. Yes, so we can also Contour is very well So you can escalate it that can you can clue you can actually Hire the dose. Yes in earlier time the dose is limited by the tolerance of the Organic reeks, but when you have a very good contour and you define the PTV very well then you can Increase the doses so the outcome is very nice. So this is actually not only the treatment planning But 3d amazing is a actually very important and and here is at the education of medical doctors is very necessary Because most of the medical doctors they know to draw to control the from the city But the other modalities they should learn it. It's not the same. Yeah, therefore the education of Colleges even the medical physicists. Yes, we know the anatomian physiology not only physics mathematics and electronics Anatomian physically I used to have my Anatomian physiology book in my in my bags because it is not actually the subject for us But we should master of the subject. Yeah, we know the language of medical doctors I cannot say please the tumor is just in the Backbone like this I talk about the anatomy with the medical doctor so long you are not serious with the anatomian physiology They do not talk with you and so you are just so therefore it is important to know the anatomian physiology Yes, most of the people forget the things is the mathematics and physics. It is my subject. No, no It is medical physics not the basic physics Well, you see here actually in these cases, you know everything and up to the Dosimetric verification and position. This is also very important. Yeah, I will explain next Our the positioning the passion here. This is very very important you have always Work with this tomography tomograph city Lineaxilators simulator and treatment planning the four are the main equipments and All the places the passion had exactly same position. Yes, you have When there is a position change then you have not correct Treatment so it is your duty It's a very very good duty to place the passion to a right position The next hour I will explain when you have a very good position with immobilization devices then you can reduce the boundary of PTV When you reduce the boundary of PTV a small PTV what you have done you have actually saved the healthy healthy Tissues and so You you do not damage the Passion you increase the dose so through the immobilization and position You can do a lot Don't think about only the very good algorithm and calculation and Everything dosimetry is every important, you know, I do not explain Dosimetry everything is but the positioning is very very when we forget sometimes we do not cooperate with the technician or Radition oncologist, please go and always think about the positioning you understand the whole chain So that you can understand this position is right or not and every time there is a Image and you compare with this maybe once in a week When you think it is more than you can do that for the positioning is very very important That is just important like the calculation and dosimetry and treatment plan so here is the objectives everybody knows destruction of tumor and little Effect and revival of tumor and this is actually the avoidance of treatment effect You know this treatment loss of function restriction of quality life. What is the therapy optimization maximum effect with minimum burden? so maybe I Speak a little bit slow Here, you know everybody the tolerance table. It is not given in actually ICRO 50 or 60 or 62, but every medical physics all over the world use this table or similar table Because it is actually the limitation of tolerant doses is given in this and see here is the Different organ and how much this organ the organ at ricks is actually You irradiate one. So when you irradiate a Part of the organ you can increase the dose and when the limitation of dose is higher Then you have the easy tax to do the plan Yes, therefore actually this table is you give you the Criteria to save the different organs Yeah, it is actually from the imami and you can find all the literature I do not explain more when you have question I can go through the table And you see here actually also very important from the medical physicist of course the radiation oncologist you know in the there is some Orgon and serial organ and this is a parallel organ. Yes, and your case on serial organ like Spinal cold yeah, then it is actually your tax is very high your responsibility very I do not Do any burden in this serial organ then you actually the function is disorder But instead of that when a parallel organ just like a light here in this room I can choose one light because parallel connection for others, but when you have a Christmas Christmas light when you see one then everything is dark That's actually the series. Yeah, everybody knowing physics, especially electro techniques How this and it is not difficult sometimes to know in who is case is parallel who is case is actually serial but the medical oncologist and Pathologists they know they also take care about this, but you understand also very important because some hospital The medical physics is the draw also the contour also the organ at risk yes, they do Not the PTV it is done by the radical Radiation oncologist, but the medical faces they can prepare for the draw all the organ at risk and they come and they check it and Maybe they extend it. Maybe if there's some correction, but you can do the organ at risk And here actually what I'm telling The fixing of treatment position is the first case then the patient there and we fix the patient here This is very important and the fixing the patient. You know this place should be very compatible The passion lying may be 30 sitting or 40 sitting So maybe he's a good to come and and lie there So it is very important to ask discuss. What is his position? What is this actually compatible for him and you do that here the immobilization and then also the question is of this city It is a diagnostic city or are simulator city And then there is a diagnostic city that you have only so orientation and you do this different slices and later in the simulator you mark very good, but when Simulator city then we have here actually the mark here on everything because the medical doctors here fixed And not only the central plane, but also actually the iso center Here the fix the iso center when you go to the treatment planning and you see already There is a field. There is a just an arbitrary field with the iso center and you start to do it. You do not search any Iso center In the treatment planning is also given Therefore here is actually your decision your hospital have your hospital has a conventional city or Simulator city So these are the devices in next hour. I will explain little bit more These are many many devices. Yeah Sometimes there is a combi boat. You have heard maybe some hospital the people they supply you the combi boat and the combi boat You can do all the placement but here is a Many many things and actually here the technician they have the Entrance to Choice these things. Yeah, but I think it is a better Together with the team they Choice the all the apparatus. I have no many my colleagues Even do not know who is the where the immobilization in this room. They do not know I asked them Can you see your immobilization? Oh technician, please come please? I do not know in which place and they search everywhere. So don't do that You know actually the immobilization devices is very important Biggie of positioning So here the city You you can do the city when everybody knows in city Actually also quality control here in cities very important. You have a city phantom you send them and You also put the quality control whether whether the different organs the density is correct The contouring is correct. Everything should be also quality control from your hospital It is not the machine of the radio diagnostic. It is a part of the machine Belongs to your department in the physics department or radio therapy department so Here is also the process actually City we know the city is actually be important. Why city is important treatment planning? Can I explain here? Yes, because we want to get radiation So when there is a radiation properties there then you can get also But the other model to have no radiation absorption properties so we can also take aids help and draw the Therefore city is must and city is actually on this without city we could not Plan it is the three-dimensional. You can see in organ places and the density So you can calculate the treatment planning So it is actually the tools for medical physics city without city We do not need any medical thesis with the projection radiography, so the medical doctors do at the only older time with conventional conventional Treatment, you know this yeah, but it's still then when conventional treatment you can need city may be one a one Level and you can do that Yeah, we have we have always irradiated 3d Can you irradiate patient 2d? Never Yeah The radiation come 3d and we always irradiated 3d, but we cannot calculate the 3d That's why the problem at that time and we could not also conform because we have no tools No multi-nip like this, but we have irradiated always 3d Yeah, now we have the tools to calculate 3d and also in hardware To conform the tumor and other organ see here is the contouring. Yes, I explain and you see here the contouring and And you can start in case of larynx here Just the outer contour then target volume in this case PTV everybody will please I explain later The planning treatment volume it is actually where we Calculate an organ at risk in different places according to the need of the patient and So here is the strategy for the medical doctors Sometimes the draw and the tumor you have seen and the decrease the volume and again increase the dose and so they call it Do more detected and two more suspected you see here is the actually I have taken these slides from medical doctors I think it is very nice The medical tumor mass and tumor localization tumor character with model it is needed So it is a It is a actually long and very very positive development even in Germany I am actually the witness of all the development because I came there 72 and Started my radio therapy medical physics in 78 at that time. There is no computer No water phantom nothing We do everything with hands and everything so I know the development only at the time Even in the hospital when they the head of the department is not there and the second people they have different Treatment volume. Yeah, you cannot compare even in the hospital yourself to the head of the Rational oncologist and his second man. Now, there is a very very positive in between the ICRU. They are given the correct definition how you need it and How you record it and everything clear? So all over the world We have the same philosophy So we can compare and even we can compare the outcome. So it is a very very positive development So the people are thinking the radiation oncology and medical physics. They are always developing and developing and developing so you start is at 29 and Then ICRO 50, you know this one and you use it and Of course this 62 is also very important. Actually, we cannot download such types of ICRO. You should buy this one and It is a very expensive but you can copy from anywhere and You can ICRO 82. Yeah, when you have MRT then 82 Then you use it. So here, I do not explain the 29 It is actually the old at the same time. You have seen here at the time. They have also the reference point Yeah, these are all But here is important the ICRO 50 They have the GTV Then you have CTV and you have PTV and you know everybody I think so GTV actually with the Amazing modalities you can detect the tumor and then with the microscopic Then you close the microscopic with the amazing modality and then you have the CTV and then actually the PTV very important the margin from setup of geometric Uncertainty as organ movement the both are in closes. So I tell you earlier I talk to you earlier when you have a better immobilization devices Then you can actually decrease the setup uncertainty these are These are actually the contouring and you have also many many things here inside like reference point, how can you define difference point according to the field arrangement and You can also hear the normalization Optimization you can find here If you have some question, I don't know it is too quick Okay Because one hour Finish it this but you can some question maybe it's not So the next one you have here The the ICRO 62 it is actually the new is here. Then you have the ITV It is actually a part of PTV When you differentiate this then it is easy for you to minimize the setup That's why they're doing that. Yeah, it's more differentiated more easy to after that your decision to eliminate some uncertainties and what is yes This is the question. We do not actually Criticize them, but sometimes it is not Possible because some education. Yes, there's always the continuous education is important. I know also hospital They have never seen like this here. There's been a new group even they have their national protocol When the national protocol they not consider this international protocol, they do not do that So also the national protocol should do what is the ICRO is going but I know many many hospitals in Germany Maybe you have a Media of information, please ask them do that and even here the OAR There is in this protocol. They have also like this is like the PTV for OAR Another PTV in the older protocol. They have not PTV like Yes, this is also the organophorics. They have some boundary. So here you can consider the movement and setup accuracy And what is important here the conformity index? This is also very important for the 62 So here actually the summary for all the modality and In what is actually CTV, ITV and PTV? I think I think it is I have also taken from the IAEA No Yes, not not the Panambra and not the What is this? Buildup not the buildup reason So therefore when you have the eye view in a treatment planning that you put the boundary You put the boundary The field boundary is more than the More than the PTV so that the 95 percent cover the PTV Yes, that's why you place the different leaps is more than the PTV Here does not Not Panambra not a buildup. So you plan so that you have 95 percent in the PTV therefore your field is If your field is not equivalent not the same as PTV's boundary, it is Larger it is a linear accelerator. Don't don't think about Panambra. Yeah, it's not a gamma Cobalt-60 machine is a tiny point. So Panabra is very less. So it is not actually the problem. Yes Okay Here is actually the reality. Yes It's not like a round shape or overall shape. It is actually the reality. So I have taken also for the medical doctors This you can see they have written everything very well. It is actually the work of radiation oncologist So here then the beam modeling this tools is very very important everybody know where is in the preparation beam modeling in the TPS on the beginners you have already the physicist And here I have started the optimization criteria a field form you can you can fill form with this Satellite blocks or Here with the multi-leaf You see here the view form and very easy for the multi-leaf Coalimeters and it's not only the treatment conformal treatment But also the planning is very nice. Yeah at the time earlier time we have four leaves in always a rectangular order or Square you have no many many leaves. So it is easy to do that But the yeah, we say when the machine is very easy For the medical doctors and then very complex for the physicist. This is the vice versa Yes, so you when the medical doctor the machine is very simple then you have more more quality control. Yes, and Every country is a new roof. They have their quality control protocol. We are doing the take daily checks weekly checks Monthly checks three monthly checks And many many work is there and it should be also in Germany even Italy the control by the official every two years whether you have done everything or not so Actually developing country. I have always the I have always the experience in developing country the physics they think they think their work is to do the treatment planning it is not Yeah, your work is actually the quality control Yeah, medical doctor do not care whether you have the quality control or not. They care that you do the treatment planning So you do the treatment planning and you finished your work go at home So some countries they have no regulation at all for the quality control. So the medical physically do not do the quality control Yeah, this is actually They they harm their the harm their professions When they think that you are doing only the treatment planning Yes, so they they do not need any medical physicist They take the technician and they pay less This for them is easy So one times when you do not develop the quality control in a hospital actually you harm your profession Yeah, sometimes you are not there the technician is there Please do the treatment planning There are many co-recommendation in the IA even you come Professor for the one it may be from Italy and you you can deploy yourself don't think Like this. I have my treatment planning with medical doctor satisfied. I go at home don't do that Then you actually harmful to your profession in medical physics because you are something the people your place in the whole chain Nobody can that you can this the meeting. It is the quality control. So here the eye view as a beam form you can adjust the treatment volume like this and it is the conformal and Optimization of energy just you are telling your medical physicist, you know the actually the Parties of radiation. That's why you are in the hospital You understand how the energy and what is its interaction with the maternity? also, you know the depth those and you know the scattering and you know the panambra, you know the Build up everything is your control. So you can optimize the energy and Here is a Entry point. This is actually the daily things when there is a tumor here How the entry point look likes? Maybe here. Maybe this We need an wage or not on every your decision to choice of best angle And here you see the numbers and waiting Yeah, when you some high, you know Actually the head and neck tumor maybe sometimes in 14 or 15 fields In the direct planning So your decision always do optimization yourself. It takes long time to do a best configuration and Waiting you're changing changing changing easier for the IMRT, but in the 3d conformal just optimize yourself with your Experiences so sometimes they are a medical physicist in the hospital may be very specialized in the TPS and he can do earlier than you at the head of the Medical physics. So it is actually your experience Some hospital. They have some standard Standard tumor and they have some standard Mask they put it it and modify it. You know in this case I have four field box built and they put it this one and Then they can change it so you can do that also when here You have the optimization wages. Yeah, please use more dynamic ways Yes, because if the technician when hundred wages in the day Then it's not so easy Maybe in different angle the chains should be changes. So the dynamic wages is very important Some cases is not possible, but I think you use also the dynamic wages so here the Type of criteria I go later. Here the combination of electron and photon Yeah, you can select in which cases photon and electron and opposite field waste And here three fields and rotational irradiation in Germany. There is no rotational at all No rotational. They do not that it actually historically the rotational The insurance did not pay because I don't know one field So the medical doctor select more fields because I have more money and now is the tradition is so The do not use actually the rotational field, but we still many cases you need it Actually, I am RT. You know this rapid arc and like this but in 3d conventional rotational feet is very seldom Here a non-coplanar. Yeah, and sometimes in head and neck a uses, you know, this 3d coplanar a non-coplanar It is sometimes, you know, the actually the geometry and the fin configuration sometimes Not easy for the beginners, but when they do some plan then they understand What is the no coplanar they move their coach and the patient because the because the head of the Only in this direction not like a gamma tone at the time. They can also be like this direction So you place your coach in other directions So now is the criteria Here is the criteria from the IC RU. You see here Plus seven percent to minus five percent. It is actually the dose inside the PTB It should be maintained When sometimes it's not possible very complex then you consult with the medical doctors and he decided Maybe less than five percent Then sir, okay, I selected but not your decision. You try always as this is to do that And this is actually the condition for the PTB and organ of ricks the condition I give the once again this table. So in this table and this condition then you can fulfill the treatment plan so here actually Optimize the dose distribution when you have all are setting together then you can optimize you can normalize and you can put actually To gray in the IC RU Point and then you have the final check final plane like this It is only you know one one Level one level, but you have different so with the help of ice ice iso-dose you cannot judge this one. So there is a new methodology it is you know this This is called Dose volume histogram. So every pixel voxel, you have the dose and you see in which dose and then you draw the volume Will fulfill this condition against the dose you see here actually the PTB is very good Homogen and applied the dose and here is the other organ of ricks So you can judge very easily for medical doctors is very One minutes they can judge in which plane is better But at the older time when only one plane then I said is okay, but now is many many Scans and you cannot judge it And here actually the case I have drawn This is the ideal case, but is not realizing the practice when the PTB in 100% that is very good and actually the organ of ricks nothing Should I should I do this conformal maybe in brachytherapy or proton therapy, but it's not with the photon Electron Brachytherapy is more conformal. Yeah, you know the brachytherapy is very important. It takes again the renaissance In radio therapy it is it cost one-third of the surgery Yes in brachytherapy again one-third cost, you know from the surgery in brachytherapy one ninth is a very very cheap but The people are medical doctors sometimes not because sometimes in Varsity, so they know They need to touch the patient here. So it is extensive work But external beam is just like the beam is there. It is easy So I Suggest in developing country do more after loading. Yeah It's a very very important even some countries like India and China. They have very Manual after loading. Yeah, when the passion load is not so high then manual after loading is also very cheap Yeah, they have seen in India $1,000 there's a manual applicator for Service carcinoma it takes long time maybe 28 hours, but they are doing some health I have seen in also Africa in Tanzania They're doing like this. So it's possible But I suggest when the frequency of passion very high you have after loading remote after loading Hydro therapy And it's important. What is the radio therapy is also very? Radio therapy is also very human when you have a radio therapy there Then you have maybe in one day in the evening a one day in the afternoon Take it free for the poor people, but you can do it chemotherapy or surgery because chemotherapy everybody need the medicine But when one half days free for the poor people They have the aid of radio therapy So here three treatment planning other three treatment planning for the same patient I select it maybe this red one. That is the best one So here is different types of different types of the treatment planning everywhere you can possible the treatment planning and Here is a very good tools the DRR, you know from the from the projection radiography You can from the cities you made the projection Radiography when you have projection radiography, then you can compare with simulator at the same times in field control All the three can you compare when they are very very Concise then you have a best position So these tools is always you do that and send from TPS to the treatment planning system and the simulator Yes Please here here the all the DRR so Then when the DRR there you can simulate the patient once again when there is no city simulator normal simulator You can simulate and see whether the Positioning is okay, and the field control verification is everything, okay, and here's the information system Here you sent not only the treatment planning, but also the DRR here once again and then again positioning the passion in the linear accelerator room once again and Then you do a image field control Here this is actually the image for control with a piece Or some film pot inside the treatment planning room, and actually this is important the DRR simulation and verification when the three three boards all the three are Fit together then you have the best situation. So and then the radio therapy Here in the whole process you have the random uncertainty and the systematic uncertainties have here list of all the Uncertainties here is the list of all the uncertainties and it should be removed through different mechanism and through different prequations and We'll explain the next hour this whole the uncertainty how can we move it through the verification through the immobilization? Through the control of those and everything so that you can minimize All the uncertainties. So you have a very successful radio therapy what you can And what is important also for you? This is a park system and most of you they have the park system Achieve and you sent everything to there because in you know the all the documents on radio therapy you should Have for 30 years Here in Germany when somebody after 10 or 20 years come and maybe ask you have bad treatment for my grandfather So you should be you should actually prove it is it is everything is okay. So 30 years the Achieve you in the Radio therapy and 10 years for on x-ray diagnostic So here all the documents You send there some hospital have their own Packs for the radio therapy department. I suggest actually every radio threat department their own packs Otherwise, there is a central packs in the radiology department and you should have your place there And you have a good cooperation with the technician of the radiologist. Maybe you have your password to go there freely and control your data yes, so it is actually the matter of Organization, but I have a small Department with their own park system. It's also good. You can Care yourself But the pack system is very easy the one of the question the medical faces Yeah, your taxes very heavy actually. Yeah, when you have the pack system when the new system come You actually convert all the data from the old system to the new system Yeah, the vendor always throw no problem. We are doing this. We supply you the Software that one after the Sold it. Yes You cannot change this. I have sometimes is a band and now the DVD and we can read the old one So how can you preserve 30 years? So actually your duty to continuous check up the third 30 years Otherwise you are she bit and after that is you cannot read it So these are all the literatures. I have used of course my experience in hospital I have finished this Financial now your question or your comments Please do that Maybe we have two or three minutes Feel free and do that. Yeah, there is no foolish question only foolish answer Yes Actually I see TV 95% I see TV is the same to yes You have a documents then you have no response we do are going to the documents but do better than the document that is allowed about not Yeah, yeah, please Yes No, no Any question, please or anyway comments on three feel free Very short time we cover everything and here is the director Maybe in the interval we can discuss more details Yeah, you have free here. You are here. No family. No girlfriends. Nothing. You are here only to do the medical physics Yeah, thank you for your attention We'll see