Beyond the Beam: A Radiation Oncology Curriculum for Radiopharmaceutical Therapy
Beyond the Beam is a 15-hour in-depth curriculum that is designed specifically for radiation oncology residents and practicing radiation oncologists who are planning or participating in a radiopharmaceutical therapy (RPT) clinical program. The course broadly covers the topics recommended for RPT education by the International Atomic Energy Agency and the Nuclear Regulatory Commission, including physics, radiobiology, chemistry, molecular imaging, dosimetry, radiation protection, regulatory issues, quality and safety, and therapy-specific considerations of the above for PSMA-targeted agents, Ra-223, RAI, Lu-DOTATATE, liver-directed RPT, and other agents.
Please see the Program tab for session information and presenters.
This activity is available from July 19, 2024, through 11:59 p.m. Eastern time on July 4, 2026.
The content was originally presented and recorded as a live webinar series, April 26-July 5, 2024.
Target Audience
This activity is designed to meet the interests of radiation oncologists, radiation physicists, radiation biologists and radiation oncology residents.
Learning Objectives
Upon completion of this activity, participants should be able to do the following:
- Appraise the pharmacokinetics (PK) and biodistribution of radioisotopes used in therapy.
- Articulate the instrumentation, mathematics, and radiation protection measures necessary for the safe and effective use of radioactivity in RPT.
- Articulate regulatory issues, standard operating procedures, and the process of becoming an authorized user in RPT, emphasizing quality assurance, patient-centered care, and safety protocols.
Part 1 - Introduction, Radiobiology I and Chemistry
- Introduction to Radiopharmaceutical Therapy and Curriculum Overview ‒ Ana Kiess, MD, PhD
- Radiobiology I (PK, Biodistribution, Dose Rate, Subcellular Targeting, Molecular and Cellular Effects of Beta/Alpha, Deterministic and Stochastic Effects, Toxicities) ‒ Ana Kiess, MD, PhD
- Chemistry of Radiopharmaceutical Therapies for Medical Use ‒ Freddy E. Escorcia, MD, PhD
In the first session, presenters introduce the curriculum, radiopharmaceutical therapies (RPTs) in general, radiobiology of RPTs, and chemistry of RPTs. This includes discussion of pharmacokinetics, biodistribution, dose rate, subcellular targeting, molecular and cellular effects of beta/alpha emitters, deterministic and stochastic effects, and toxicities.
Part 2 - Dosimetry I and II and Radiobiology II
- Dosimetry I – Dosimetry Methods and Individual Dose Planning, Uncertainties ‒ Yuni Dewaraja, PhD
- Dosimetry II / Radiobiology II – Bioeffect Modeling, Tumor Dose-Response, Toxicities, Alpha Emitters ‒ Robert Francois Hobbs, PhD
The first presentation introduces methods for performing organ-level and voxel-level radiopharmaceutical therapy (RPT) dosimetry. The reference model-based MIRD formulism as well as direct Monte Carlo based methods for highly patient specific dose estimation using the patient’s SPECT and CT images as the input are discussed. The main steps of the dosimetry calculation including serial imaging, activity quantification, image registration, segmentation, time-activity fitting, and absorbed dose estimation are introduced together with the main sources of uncertainty. How individualized dosimetry before, during and after therapy can enhance RPT are covered. Methods for simplifying the dosimetry protocol to make it practical for clinical implementation are discussed including recently available AI-based tools.
In the second presentation, basic bio-effect modeling based on the linear-quadratic model is introduced. A large focus is on the biological effective dose (BED), how it is calculated, why it should be more utilized in RPT than in external beam (EBRT), and why it is a better correlate with outcome than absorbed dose. The presentation explores the theoretical comparison of EBRT and RPT doses and the limitations of that translation, especially with regard to normal organ toxicity threshold determination in RPT. Finally, the particularities and challenges of alphaRPTs are explored, including low count rate imaging, radioactive daughters, sub-organ dosimetry, the relative biological effect (RBE), and stochastic energy deposition.
Part 3 - Physics I and Principles of Clinical Molecular Imaging
- Physics I – Image Acquisition and Quantitation (PET, SPECT) ‒ Rameshwar Prasad, MS, PhD
- Principles of Clinical Molecular Imaging for Radiopharmaceutical Therapy ‒ Vikas Prasad, MD, PhD
Molecular imaging using PET and SPECT is an increasingly used for cancer diagnosis, treatment, and treatment response evaluation. Recent progress in radiopharmaceutical therapy demands effective and quantitative PET and SPECT imaging application for seeing the cancer targets and visualizing what has been treated. In the first presentation, principles of PET and SPECT imaging, challenges and application of quantitation are discussed.
Imaging works as a gatekeeper for theranostics. The second presentation elucidates the significance of target (PSMA, somatostatin receptors) visualization, quantification and heterogeneity in treatment of patients with Lu-177 DOTATATE and Lu-177 PSMA. Methods for response assessments of Lu-177 PSMA and Lu-177 DOTATATE are also briefly discussed.
Part 4 - Physics II, III and IV
- Physics II – Instrumentation and Mathematics Pertaining to the Use and Measurement of Radioactivity ‒ Rameshwar Prasad, MS, PhD
- Physics III – Radiation Protection for Radiopharmaceutical Therapies ‒ Jessica Clements, MS
- Physics IV – Regulatory Issues and Standard Operating Procedures ‒ Jacqueline Esthappan Zoberi, PhD
The first presentation covers principles of radioactivity and its measurement challenges. Various instruments for measuring and analyzing the radioactivity are also explained.
The second presentation covers some radiation safety basics related to starting up a new radiopharmaceutical therapy program. These include updating the facility radioactive materials license, patient screening and education along with some special situations presented by patients, management of household waste, preparing for treatment day, release criteria, and after-treatment care.
The third presentation focuses on the development of standard operating procedures (SOPs) as one of a number of tasks for implementing a radiopharmaceutical therapy. In order to develop an SOP, one needs to learn about the therapy, allocate resources, and be familiar with radioactive material use regulations.
Part 5 - Quality and Safety
- Principles of Patient-Centered Clinical Radiopharmaceutical Therapy: Quality and Safety ‒ Hyun Kim, MD
The session provides instruction on ensuring quality and safety in radiopharmaceutical programs. There are many unique considerations for quality assurance in radiopharmaceutical therapy, such as workflow checklists for treatment delivery and post-treatment dosimetry. Further, responses to medical emergencies require special planning to prevent contamination of the clinic and emergency response personnel.
Part 6 - Therapy-Specific Considerations I
- Therapy-Specific Considerations for Lu-PSMA-617 ‒ Jeff M. Michalski, MD, MBA, FASTRO
- Therapy-Specific Considerations for Ra-223 ‒ Richard G. Stock, MD
In this session, the presenters review the role of prostate specific membrane antigen (PSMA) in the staging, localization, and targeting of prostate cancer. Diagnostic PET imaging agents such as 18F-piflufostat, 18F-flotufolastat, and 68Ga-gozetotide are allowing more accurate detection of early recurrent prostate cancer after either prior prostatectomy or definitive radiation therapy. They can also be used to select patients that may respond to radioligand therapy that employ similar PSMA-avid ligands that are linked to a therapeutic radioisotope. The first PSMA avid radioligand is 177Lu-vipivotide tetraxetan, which has been shown to prolong survival and maintain quality of life of men with castrate resistant prostate cancer. Clinical trials with similar drugs in various prostate cancer disease states are ongoing.
The role of RA-233 and its applications are also discussed.
Part 7 - Therapy-Specific Considerations II
- Therapy-Specific Considerations for RAI ‒ Stephanie Markovina, MD, PhD and Nikhil Rammohan, MD, PhD
- Therapy-Specific Considerations for Liver-Directed Radiopharmaceutical Therapy/Selective Internal Radiation Therapy ‒ Andrew S. Kennedy, MD
The first presentation, Therapy Specific Considerations for RAI, reviews the therapy-specific considerations for RAI toward the treatment of thyroid cancer. Discussion includes the basic mechanism, indications and toxicities of RAI therapy.
Hepatic brachytherapy using intra-arterial Y90 microspheres is a maturing therapy that often is delivered without the concomitant application of personalized dosimetry planning and post-treatment confirmatory dosimetry, multidisciplinary consultation, and collaborative management prior to and post liver-directed RPT. The second presentation, Therapy-Specific Considerations for Liver-Directed RPT/SIRT, reviews the eligibility criteria for liver-directed radiotherapy using Y90 and the estimated absorbed does in tumor and normal live prior to and after implementation.
Part 8 - Therapy-Specific Considerations III
- Therapy-Specific Considerations for Lu-DOTATATE ‒ Hyun Kim, MD
This session provides instruction on the clinical data and practical considerations for lutetium Lu 177 dotatate treatment.
Part 9 - Prior Authorization and Future Applications
- Miscellaneous and Future Applications of Radiopharmaceutical Therapy – How to Become an Authorized User, Meta-iodobenzylguanidine, Rhenium Skin Cancer Therapy, Radiosynoviorthesis, Alpha Emitters, Other ‒ Michael Folkert, MD, PhD
This session reviews miscellaneous and future applications of radiopharmaceutical therapy, many of which are under development or in use outside of the U.S. Presenters discuss radiopharmaceutical applications such as meta-iodobenzylguanidine (MIBG) therapy, topical rhenium skin cancer therapy, radiosynoviorthesis, palliative radiopharmaceutical therapies, indications in hematologic malignancies, and the increasing role of alpha emitters in radiopharmaceutical therapies. Presenters also touch on how to become an authorized user for administration of radiopharmaceutical therapies.
- Ana Kiess, MD, PhD, is employed by Johns Hopkins University. Dr. Kiess receives grant/research funding from Bayer and serves in an uncompensated consultant role with Novartis/AAA.
- Freddy E. Escorcia, MD, PhD, is employed by the National Cancer Institute.
- Rameshwar Prasad, MS, PhD, is employed by UT Southwestern Medical Center.
- Vikas Prasad, MD, PhD, is employed by Washington University School of Medicine in St. Louis. Dr. Prasad receives honoraria and grant/research funding from Curium and travel expenses from Telix. Dr. Prasad serves as a Pillar Lead with ICPO Academy, is an advisory board member with ENETS and is a faculty member with ESMO.
- Jessica Clements, MS, is employed by the University of Vermont Medical Center and is Owner of Evergreen Medical Physics, LLC. Ms. Clements receives travel expenses from AAPM; honoraria from MTMI; and compensation from the American College of Radiology. Ms. Clements serves in a volunteer role with AAPM and serves as Chair of the Diagnostic Medical Physics Oral Exam Committee with the American Board of Radiology.
- Jacqueline Esthappan Zoberi, PhD, is employed by Washington University School of Medicine in St. Louis. Dr. Zoberi serves as education/meeting faculty with ASTRO. Dr. Zoberi serves as Chair of the Education and Training Committee on Medical Physics and is a Board member-at-large with AAPM.
- Robert F. Hobbs, PhD, is employed by Johns Hopkins Medical Institute. Dr. Hobbs receives honoraria from Novartis/AAA and Varian. Dr. Hobbs receives compensation from Vivos. Dr. Hobbs owns the copyright for RAPID Dosimetry. Dr. Hobbs serves as Chair of the Radiopharmaceutical Therapy Subcommittee with AAPM.
- Hyun Kim, MD, is employed by Washington University School of Medicine in St. Louis. Dr. Kim receives grant/research funding from Varian and ViewRay. Dr. Kim receives compensation from Novartis. Dr. Kim is the Founder/CEO of GlobalART. Dr. Kim is Associate Editor of IJROBP.
- Jeff M. Michalski, MD, MBA, FASTRO, is employed by Washington University School of Medicine in St. Louis. Dr. Michalski receives travel expenses/compensation from Michalski and Associates and receives grant/research funding from NCI. Dr. Michalski is Treasurer of the RTOG Foundation and Co-Chair of the GU Steering Committee with NCI.
- Richard G. Stock, MD, is employed by Icahn School of Medicine at Mount Sinai. Dr. Stock receives honoraria from Grand Rounds in Urology and Accuray.
- Stephanie S. Markovina, MD, PhD, is employed by Washington University School of Medicine in St. Louis. Dr. Markovina receives travel expenses from NCCN. Dr. Markovina is the PI on research grants with the National Cancer Institute/NIH and Tesaro, Inc.
- Nikhil Rammohan, MD, PhD, is employed by Washington University School of Medicine in St. Louis.
- Andrew Kennedy, MD, is employed by the Sarah Cannon Cancer Center at TriStar Health. Dr. Kennedy receives compensation from ABK Medical and Bard.
- Michael Folkert, MD, PhD, is employed by Northwell Health. Dr. Folkert serves as Education Subcommittee Chair with the American Brachytherapy Society and is a radiation oncologist representative with the Advisory Committee on the Medical Uses of Isotopes.
- Yuni Dewaraja, PhD, is employed by University of Michigan Medicine. Dr. Dewaraja receives compensation from MIM Software and grant/research funding from GE Healthcare.
The person(s) above served as the developer(s) of this activity. Additionally, the Education Committee had control over the content of this activity. All relevant relationships have been mitigated.
The American Society for Radiation Oncology (ASTRO) is accredited by the Accreditation Council of Continuing Medical Education to provide continuing education to physicians.
ASTRO is awarded Deemed Status by the American Board of Radiology to provide SA-CME as part of Part II Maintenance of Certification.
Available Credit
- 15.00 AMA PRA Category 1 Credit™The American Society for Radiation Oncology (ASTRO) is accredited by the Accreditation Council for Continuing Medical Education for physicians. ASTRO designates this for a maximum of 15.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 15.00 Certificate of AttendanceThis activity was designated for 15.00 AMA PRA Category 1 Credit™.
Price
Course Fees:
ASTRO members must log in to the ASTRO website to view and receive the member rate.
Nonmember: $799
Member: $599
Member-in-training: $99
Member Student/Grad Student/PGY: $99
Member Postdoctoral Fellow: $99
Policies:
No refunds, extensions, or substitutions will be made for those participants who, for any reason, have not completed the course by the end of the qualification date.
Participants using ASTRO's online courses to satisfy the requirement of a Maintenance of Certification (MOC) program should verify the number, type and availability dates of any course before making a purchase. No refunds, extensions, or substitutions will be made for participants who have purchased courses that do not align with their MOC requirement.
The course and its materials will only be available on the ASTRO website until July 4, 2026, regardless of purchase date. At the expiration of the qualification, participants will no longer have access to the course or its materials. ASTRO reserves the right to remove a course before the end of its qualification period.
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