Particle Therapy Research Articles

Conceptual Design of an HTS Canted Cosine Theta Dipole Magnet for Research and Hadron Therapy Accelerators

Conceptual Design of an HTS Canted Cosine Theta Dipole Magnet for Research and Hadron Therapy Accelerators

527 Clinical benefit of Hadron therapy (p+ and C+)

527 Clinical benefit of Hadron therapy (p+ and C+)

Design of a large energy acceptance beamline using fixed field accelerator optics

Large energy acceptance arcs have been proposed for applications such as cancer therapy, muon accelerators, and recirculating linacs. The efficacy of hadron therapy can be improved by reducing the energy layer switching time, however this is currently limited by the small momentum acceptance of the beam delivery system (<±1%). A “closed-dispersion arc” with a large momentum acceptance has the potential to remove this bottleneck, however such a beamline has not yet been constructed. We have developed a design methodology for large momentum acceptance arcs with Fixed Field Accelerator optics, applying it to a demonstrator beam delivery system for protons at 0.5–3.0 MeV (±42% momentum acceptance) as part of the Technology for Ultra-Rapid Beam Operation project at the University of Melbourne. Using realistic magnetic fields, a beamline has been designed with zero dispersion at either end. An algorithm has been devised for the construction of permanent magnet Halbach arrays for this beamline with multipole error below one part in 104, using commercially available magnets. The sensitivity to errors has been investigated, finding that the delivered beam is robust in realistic conditions. This study demonstrates that a closed-dispersion arc with fixed fields can achieve a large momentum acceptance, and we outline future work required to develop these ideas into a complete proof-of-principle beam delivery system that can be scaled up for a medical facility. Published by the American Physical Society 2024

Status of LET assessment with active and passive detectors in ion beams

This review explores current experimental methods for determining the radiation quality in ion beams. In this context, radiation quality is commonly evaluated using the averaged linear energy transfer (LET), a metric employed to assess the response of both biological and physical systems. Dose and averaged LET can be experimentally determined with passive detectors through various techniques that have seen recent improvements. Another metric related to the LET is the mean lineal energy, which is measurable using microdosimetric detectors. This review focuses on the available possibilities for evaluating the radiation quality using three microdosimeters (mini-TEPC, Silicon Telescope, and SOI Microplus), three passive luminescence detectors (based on optical, thermo-, and radiophoto-luminescence), three track-based detectors (track-etched detector, Timepix, fluorescent nuclear track detector), and a chemical detector based on alanine. A comparison of detector properties is provided along with an overview of the underlying mechanisms enabling LET assessment or measurements of the mean lineal energy with each detector type. Finally, this review summarizes the current possibilities of LET determination with respect to the needs for quality assurance in particle therapy. Areas for future research and development are suggested.

Charge measurement with nuclear emulsions spectrometers for hadron therapy fragmentation cross section measurements with the FOOT experiment

Experimental data concerning projectile and target fragmentation is limited, increasing the uncertainty on the dose in the entrance channel in particle therapy treatments. The FOOT experiment measures nuclear fragmentation cross sections with two complementary detectors. The performance of the FOOT nuclear emulsion detectors in identifying the charge of nuclear fragments has recently been studied using 16O beams at 200 and 400MeV/n, directed at carbon and polyethylene targets. This work extends the previous analysis, comparing experimental data and FLUKA Monte Carlo predictions, focusing on the angular distribution and relative abundances of fragments with Z≤5 originating from the interactions of a 400MeV/n oxygen beam with a carbon target.

Deep learning-based voxel sampling for particle therapy treatment planning

Objective. Scanned particle therapy often requires complex treatment plans, robust optimization, as well as treatment adaptation. Plan optimization is especially complicated for heavy ions due to the variable relative biological effectiveness. We present a novel deep-learning model to select a subset of voxels in the planning process thus reducing the planning problem size for improved computational efficiency. Approach. Using only a subset of the voxels in target and organs at risk (OARs) we produced high-quality treatment plans, but heuristic selection strategies require manual input. We designed a deep-learning model based on P-Net to obtain an optimal voxel sampling without relying on patient-specific user input. A cohort of 70 head and neck patients that received carbon ion therapy was used for model training (50), validation (10) and testing (10). For training, a total of 12 500 carbon ion plans were optimized, using a highly efficient artificial intelligence (AI) infrastructure implemented into a research treatment planning platform. A custom loss function increased sampling density in underdosed regions, while aiming to reduce the total number of voxels. Main results. On the test dataset, the number of voxels in the optimization could be reduced by 84.8% (median) at <1% median loss in plan quality. When the model was trained to reduce sampling in the target only while keeping all voxels in OARs, a median reduction up to 71.6% was achieved, with 0.5% loss in the plan quality. The optimization time was reduced by a factor of 7.5 for the total AI selection model and a factor of 3.7 for the model with only target selection. Significance. The novel deep-learning voxel sampling technique achieves a significant reduction in computational time with a negligible loss in the plan quality. The reduction in optimization time can be especially useful for future real-time adaptation strategies.

Current trends and future perspectives in hadron therapy: radiobiology

PurposeThe purpose of this article was to highlight current and future trends in radiobiology in an effort to move hadron therapy forward through the application of new knowledge in DNA damage and subsequent response to heavy ion radiotherapy, immune oncology and the interconnection between.MethodsThe subject matter begins with a description of the role of radiation in eliciting either an immunogenic or tolerogenic response to radiation exposure. The role of fragmented DNA in an immunogenic response is described, followed by the definitive role that DNA damage and subsequent repair, or not, of complex DNA damage after hadron exposure plays in the survival response of hadron irradiated cells.ResultsThe process by which ionizing radiation elicits an immunogenic rather than tolerogenic response is becoming clearer. The timing of fractionated radiotherapy when combined with an immune checkpoint inhibitor is not clear and may be tumor site specific. Furthermore, whether hadron therapy is more effective at generating a durable immunogenic response is unknown.ConclusionsCytosolic DNA plays a significant role in eliciting an innate immune response with the likelihood that hadron therapy would generate complex DNA damage that because it is less likely to be repaired, is more likely to become cytosolic DNA, and more likely to activate an immunogenic response. Lastly, DNA repair pathway choice appears to be a credible bio-indicator for hadron therapy selection as well identify druggable targets to enhance hadron therapy.

Stopping power and range estimations in proton therapy based on prompt gamma timing: motion models and automated parameter optimization

Objective. Particle therapy treatments are currently limited by uncertainties of the delivered dose. Verification techniques like Prompt-Gamma-Timing-based Stopping Power Estimation (PGT-SPE) may allow for reduction of safety margins in treatment planning. Approach. From Prompt-Gamma-Timing measurements, we reconstruct the spatiotemporal distribution of prompt gamma emissions, which is linked to the average motion of the primary particles. The stopping power is determined by fitting a model of the average particle motion. Here, we compare a previously published implementation of the particle motion model with an alternative formulation and present two formulations to automatically select the hyperparameters of our procedure. The performance was assessed using Monte-Carlo simulations of proton beams (60 MeV–219 MeV) impinging on a homogeneous PMMA phantom. Main results. The range was successfully determined within a standard deviation of 3 mm for proton beam energies from 70 MeV to 219 MeV. Stopping power estimates showed errors below 5% for beam energies above 160 MeV. At lower energies, the estimation performance degraded to unsatisfactory levels due to the short range of the protons. The new motion model improved the estimation performance by up to 5% for beam energies from 100 MeV to 150 MeV with mean errors ranging from 6% to 18%. The automated hyperparameter optimization matched the average error of previously reported manual selections, while significantly reducing the outliers. Significance. The data-driven hyperparameter optimization allowed for a reproducible and fast evaluation of our method. The updated motion model and evaluation at new beam energies bring us closer to applying PGT-SPE in more complex scenarios. Direct comparison of stopping power estimates between treatment planning and measurements during irradiation would offer a more direct verification than other secondary-particle-based techniques.

Evolution of hadron therapy from 1935 to 2005: a personal view

IntroductionHadron therapy is today an established modality in cancer radiation therapy that, world-wide, is available in about hundred centres. About 90% of them are devoted to proton therapy and the rest also to carbon ion therapy. Based on the superior ballistic and radiobiological properties of fast ions, this discipline experienced a remarkable growth in the last 30 years.PurposeThis paper reviews the history of hadron therapy starting from the initial work done at Berkeley in the 30’s.MethodsFast neutron therapy is not forgotten but the main accent is on the parallel development of proton and carbon ion therapy. For space reasons pion therapy, to which a lot of efforts have been devoted without success, is not discussed.ResultsThe activities of the main protagonists in USA, Japan and Europe are shortly presented so that the reader can appreciate the relevance of the contribution given by each of them to the advancement of the field.ConclusionsThe review ends in 2005, when the carbon ion centres HIT in Heidelberg and CNAO in Pavia were under construction, with the aim of putting at the disposal of European citizens advanced treatments of radioresistant tumours, which cannot be effectively treated neither with X rays nor with protons.

Method for fabricating a mesh ripple filter for charged-particle therapy

Objective. A simple, low-cost ripple filter consisting of multiple mesh sheets (mRiFi) was previously developed to reproducibly widen the Bragg peak of heavy-ion beams. To fabricate the mRiFi, the mRiFi parameters such as the wire material, wire diameter, wire spacing, and number of mesh sheets had to be determined. However, it was unclear how these parameters contribute to shifting and widening of the Bragg peak as well as to lateral spreading of the beam passing through the mRiFi. The purposes of this study were to clarify the contributions and to propose a recipe for fabricating a mRiFi with the desired performance values. Approach. We established an analytical calculation method to estimate shifting and widening of the Bragg peak and lateral spreading of heavy-ion beams passing through the mRiFi for given mRiFi parameter values. We also performed Monte Carlo simulations to validate the analytical calculation method. The recipe for fabricating the mRiFi with desired performances was established based on the analytical calculation method. Using the recipe, we fabricated the mRiFi for multi-ion therapy and evaluated its performance through demonstration experiments with helium-, carbon-, oxygen-, and neon-ion beams. Main results. The difference between the results of the Monte Carlo simulation and the analytical calculation was less than 0.4 mm for the peak shift, 0.15 mm for the peak width, and less than 0.11 mm for the lateral beam size which validated the analytical calculation method. The experimentally observed shift and width of the Bragg peak were consistent with the analytical calculations. Significance. We proposed a method to determine mRiFi parameters for fabricating a mRiFi with a desired performance, i.e. adequate widening of the Bragg peak with an acceptable peak shift and lateral beam spread. The proposed method allows anyone to fabricate a simple and low-cost mRiFi satisfying desired specifications.

Zircoborate glass-ceramic composite reinforced with aluminum oxynitride: Microstructural evolution, physical properties, and charged radiation attenuation analysis

This study used the powder metallurgy method to create aluminum oxynitride (AlON)-reinforced zircoborate glass-ceramic composites. The solid-phase reaction method was used to synthesize AlON powder, which was then added to Zr-based glass-ceramic in different amounts (0, 4, and 8 % by weight) to make it stronger and harder. The prepared materials were characterized for their structural, physical, and radiation shielding properties. The density of GZr8 (AlON-free) had a value of 2.9 g/cm3, and the sintered glass-ceramic density with 4 % wt. AlON reinforcement (GZr8Al4) reached 3.05 g/cm3. The highest density of 3.11 g/cm3 was obtained for the GZr8Al8 sample with 8 % AlON wt. The Vickers hardness for GZr8, GZr8Al4, and GZr8Al8 was measured to be 4.89, 5.94, and 6.33 GPa, respectively. The AlON-reinforced GZr8 samples had fast neutron (FN) removal cross-sections of 0.0796 cm−1 and 0.0824 cm−1 for AlON content of 4 and 8 wt%, respectively. Generally, the coherent scattering cross-section (σcoh), incoherent scattering cross-section (σinc), and absorption cross-section (σabs) of thermal neutrons (TNs) increase from 0.047856 cm−1, 0.02072 cm−1, and 0.01498 cm−1, respectively for GZr8 to 0.53124 cm−1, 0.02074 cm−1, and 0.01795 cm−1, for GZr8Al8. AlON was proven to improve the ability of the Zr-based glass-ceramics to attenuate FNs and TNs. Stopping powers of electrons, protons, alpha particles and carbon ions increase with the AlON content of the materials. Comparatively, the range of charged radiation in AlON-rich samples is lower. The inclusion of AlON in the matrix of the Zr-based glass-ceramics makes it more efficient at absorbing charged radiation and can be used in ion beam or hadron therapy, ion beam analysis, or other charged radiation environments as an absorber.

Investigation of dosimetric effect of beam current fluctuations in synchrotron-based proton PBS continuous scanning

Objective. In proton pencil beam scanning (PBS) continuous delivery, the beam is continuously delivered without interruptions between spots. For synchrotron-based systems, the extracted beam current exhibits a spill structure, and recent publications on beam current measurements have demonstrated significant fluctuations around the nominal values. These fluctuations potentially lead to dose deviations from those calculated assuming a stable beam current. This study investigated the dosimetric implications of such beam current fluctuations during proton PBS continuous scanning. Approach. Using representative clinical proton PBS plans, we performed simulations to mimic a worst-case clinical delivery environment with beam current varies from 50% to 250% of the nominal values. The simulations used the beam delivery parameters optimized for the best beam delivery efficiency of the upcoming particle therapy system at Mayo Clinic Florida. We reconstructed the simulated delivered dose distributions and evaluated the dosimetric impact of beam current fluctuations. Main results. Despite significant beam current fluctuations resulting in deviations at each spot level, the overall dose distributions were nearly identical to those assuming a stable beam current. The 1 mm/1% Gamma passing rate was 100% for all plans. Less than 0.2% root mean square error was observed in the planning target volume dose-volume histogram. Minimal differences were observed in all dosimetric evaluation metrics. Significance. Our findings demonstrate that with our beam delivery system and clinical planning practice, while significant beam current fluctuations may result in large local move monitor unit deviations at each spot level, the overall impact on the dose distribution is minimal.

Research Trends in the Study of the Relative Biological Effectiveness: A Bibliometric Study.

The relative biological effectiveness is a mathematical quantity first defined in the 1950s. This has resulted in more than 4,000 scientific papers published to date. Yet defining the correct value of the RBE to use in clinical practice remains a challenge. A scientific analysis in the radiation research literature can provide an understanding of how this mathematical quantity has evolved. The purpose of this study is to investigate documents published since 1950 using bibliometric indicators and network visualization. This analysis seeks to provide an assessment of global research activities, key themes, and RBE research within the radiation-related field. It strives to highlight top-performing authors, organizations, and nations that have made major contributions to this research domain, as well as their interactions. The Scopus Collection was searched for articles and reviews pertaining to RBE in radiation research from 1950 through 2023. Scopus and Bibiometrix analytic tools were used to investigate the most productive countries, researchers, collaboration networks, journals, along with the citation analysis of references and keywords. A total of 4,632 documents were retrieved produced by authors originating from 71 countries. Publication trends could be separated in 20-year groupings beginning with slow accrual from 1950 to 1970, an early rise from 1970-1990, followed by a sharp increase in the years 1990s-2010s that matches the development of charged particle therapy in clinics worldwide and opened discussion on the true value of the RBE in proton beam therapy. Since the 2010s, a steady 200 papers, on average, have been published per year. The United States produced the most publications overall (N = 1,378) and Radiation Research was the most likely journal to have published articles related to the RBE (606 publications during this period). J. Debus was the most prolific author (112 contributions, with 2,900 citations). The RBE has captured the research interest of over 7,000 authors in the past decade alone. This study supports that notion that the growth of the body of evidence surrounding the RBE, which started 75 years ago, is far from reaching its end. Applications to medicine have continuously dominated the field, with physics competing with Biochemistry, Genetics and Molecular Biology for second place over the decades. Future research can be predicted to continue.

Clinical practice in European centres treating paediatric posterior fossa tumours with pencil beam scanning proton therapy

Background and purposeAs no guidelines for pencil beam scanning (PBS) proton therapy (PT) of paediatric posterior fossa (PF) tumours exist to date, this study investigated planning techniques across European PT centres, with special considerations for brainstem and spinal cord sparing. Materials and methodsA survey and a treatment planning comparison were initiated across nineteen European PBS-PT centres treating paediatric patients. The survey assessed all aspects of the treatment chain, including but not limited to delineations, dose constraints and treatment planning. Each centre planned two PF tumour cases for focal irradiation, according to their own clinical practice but based on common delineations. The prescription dose was 54 Gy(RBE) for Case 1 and 59.4 Gy(RBE) for Case 2. For both cases, planning strategies and relevant dose metrics were compared. ResultsSeventeen (89 %) centres answered the survey, and sixteen (80 %) participated in the treatment planning comparison. In the survey, thirteen (68 %) centres reported using the European Particle Therapy Network definition for brainstem delineation. In the treatment planning study, while most centres used three beam directions, their configurations varied widely across centres. Large variations were also seen in brainstem doses, with a brainstem near maximum dose (D2%) ranging from 52.7 Gy(RBE) to 55.7 Gy(RBE) (Case 1), and from 56.8 Gy(RBE) to 60.9 Gy(RBE) (Case 2). ConclusionThis study assessed the European PBS-PT planning of paediatric PF tumours. Agreement was achieved in e.g. delineation-practice, while wider variations were observed in planning approach and consequently dose to organs at risk. Collaboration between centres is still ongoing, striving towards common guidelines.

MR-PVHEE: A novel magnetic resonance-guided parallel-beam very high-energy electron radiotherapy system

PurposeMR-guided very high-energy electron (VHEE) radiotherapy can combine the imaging advantages of MR with the dosimetry advantages of VHEE radiotherapy, which is of significant clinical value. However, VHEEs are highly susceptible to the Lorentz force generated by the MR magnetic field, and coupling MR and VHEEs is challenging. Here, we present a novel MR-guided parallel-beam VHEE (MR-PVHEE) radiotherapy system and confirm its feasibility and effectiveness. MethodThe proposed MR-PVHEE radiotherapy system includes an ingenious coupling model of MR and VHEEs and an electromagnetic steering parameters commissioning (ESP-COM) method for accurate delivery. First, by generating parallel VHEE (PVHEE) beamlets that point in the same direction as the MR main magnetic field, the coupling model based on triple-stage electromagnetic steering can significantly lessen the twisting and deflecting of the VHEE beamlets' delivery trajectory caused by the MR magnetic field. The dosimetric advantage of VHEEs will be enhanced by delicately utilizing the MR magnetic field to constrain lateral scatter. Then, the ESP-COM method based on Bayesian black-box optimization for the PVHEE beamlets is designed by constructing a cost function using the position and direction information of particles in phase space and optimizing the parameters to deliver the beamlets accurately to the target spots. Finite element electromagnetic modeling and Monte Carlo particle transport simulation are used to validate the MR-PVHEE. ResultsMR-PVHEE can generate the PVHEE beamlets in the same direction as the MR magnetic field and accurately deliver them to the target spots. The average position error is within 0.5 mm, and the average direction error is about 0.5°, which can meet the requirements of clinical treatment accuracy. MR-PVHEE can reduce the VHEE lateral penumbra and increase the dose drop gradient. ConclusionFor the first time, MR and VHEE radiotherapy are successfully coupled in this study, and the innovative MR-PVHEE radiotherapy system can elicit new modalities for MR-guided charged particle radiotherapy and spatially fractionated radiotherapy.

Patterns of practice of image guided particle therapy for cranio-spinal irradiation: A site specific multi-institutional survey of European Particle Therapy Network

PurposeTo investigate the current practice patterns in image-guided particle therapy (IGPT) for cranio-spinal irradiation (CSI). MethodsA multi-institutional survey was distributed to European particle therapy centres to analyse all aspects of IGPT. Based on the survey results, a Delphi consensus analysis was developed to define minimum requirements and optimal workflow for clinical practice. The centres participating in the institutional survey were invited to join the Delphi process. ResultsEleven centres participated in the survey. Imaging for treatment planning was rather similar among the centres with Computed Tomography (CT) being the main modality. For positioning verification, 2D IGPT was more commonly used than 3D IGPT. Two centres performed routinely imaging for plan adaptation, by the rest ad hoc. Eight centres participated in the Delphi consensus analysis. The full consensus was reached on the use of CT imaging without contrast for treatment planning and the role of magnetic resonance imaging (MRI) in target and organs-at-risk delineation. There was an agreement on the necessity to perform patient position verification and correction before each isocentre. The most important outcome was the clear need for standardization and harmonization of the workflow. ConclusionThere were differences in CSI IGPT clinical practice among the European particle therapy centres. Moreover, the optimal workflow as identified by experts was not yet reached. There is a strong need for consensus guidelines. The state-of-the-art imaging technology and protocols need to be implemented into clinical practice to improve the quality of IGPT for CSI.

Potential Benefits of Combining Proton or Carbon Ion Therapy with DNA Damage Repair Inhibitors.

The use of charged particle radiotherapy is currently increasing, but combination therapy with DNA repair inhibitors remains to be exploited in the clinic. The high-linear energy transfer (LET) radiation delivered by charged particles causes clustered DNA damage, which is particularly effective in destroying cancer cells. Whether the DNA damage response to this type of damage is different from that elicited in response to low-LET radiation, and if and how it can be targeted to increase treatment efficacy, is not fully understood. Although several preclinical studies have reported radiosensitizing effects when proton or carbon ion irradiation is combined with inhibitors of, e.g., PARP, ATR, ATM, or DNA-PKcs, further exploration is required to determine the most effective treatments. Here, we examine what is known about repair pathway choice in response to high- versus low-LET irradiation, and we discuss the effects of inhibitors of these pathways when combined with protons and carbon ions. Additionally, we explore the potential effects of DNA repair inhibitors on antitumor immune signaling upon proton and carbon ion irradiation. Due to the reduced effect on healthy tissue and better immune preservation, particle therapy may be particularly well suited for combination with DNA repair inhibitors.

Towards precise LET measurements based on energy deposition of therapeutic ions in Timepix3 detectors

Objective. There is an increasing interest in calculating and measuring linear energy transfer (LET) spectra in particle therapy in order to assess their impact in biological terms. As such, the accuracy of the particle fluence energy spectra becomes paramount. This study focuses on quantifying energy depositions of distinct proton, helium, carbon, and oxygen ion beams using a silicon pixel detector developed at CERN to determine LET spectra in silicon. Approach. While detection systems have been investigated in this pursuit, the scarcity of detectors capable of providing per-ion data with high spatial and temporal resolution remains an issue. This gap is where silicon pixel detector technology steps in, enabling online tracking of single-ion energy deposition. The used detector consisted of a 300 µm thick silicon sensor operated in partial depletion. Main results. During post-processing, artifacts in the acquired signals were identified and methods for their corrections were developed. Subsequently, a correlation between measured and Monte Carlo-based simulated energy deposition distributions was performed, relying on a two-step recalibration approach based on linear and saturating exponential models. Despite the observed saturation effects, deviations were confined below 7% across the entire investigated range of track-averaged LET values in silicon from 0.77 keV µm−1 to 93.16 keV µm−1. Significance. Simulated and measured mean energy depositions were found to be aligned within 7%, after applying artifact corrections. This extends the range of accessible LET spectra in silicon to clinically relevant values and validates the accuracy and reliability of the measurements. These findings pave the way towards LET-based dosimetry through an approach to translate these measurements to LET spectra in water. This will be addressed in a future study, extending functionality of treatment planning systems into clinical routine, with the potential of providing ion-beam therapy of utmost precision to cancer patients.

Secondary cancer risk assessment in healthy organs following craniospinal irradiation

Introduction Medulloblastoma is a central nerves tumor that often occurs in pediatrics. The main radiotherapy technique for this tumor type is craniospinal irradiation (CSI), through which the whole brain and spinal cord are exposed to radiation. Due to the immaturity of healthy organs in pediatrics, radiogenic side effects such as second cancer are more severe. Accordingly, the current study aimed to evaluate the risk of secondary cancer development in healthy organs following CSI. Materials and methods Seven organs at risk (OARs) including skin, eye lens, thyroid, lung, liver, stomach, bladder, colon, and gonads were considered and the dose received by each OAR during CSI was measured inside an anthropomorphic RANDO phantom by TLDs. Then, the mean obtained dose for each organ was used to estimate the probability of secondary malignancy development according to the recommended cancer risk coefficients for specific organs. Results The results demonstrated that the stomach and colon are at high risk of secondary malignancy occurrence, while the skin has the lowest probability of secondary cancer development. The total received dose after the treatment course by all considered organs was lower than the corresponding tolerable dose levels. Conclusions From the results, it can be concluded that some OARs during CSI are highly at risk of secondary cancer development. This issue may be of concern due to organ immaturity in pediatrics which can intensify the radiogenic effects of radiation exposure. Accordingly, strict shielding the OARs during craniospinal radiotherapy and/or sparing them from the radiation field through modern techniques such as hadron therapy is highly recommended.

The current state and future perspectives of radiotherapy for cervical cancer.

Radiotherapy is an effective treatment method for cervical cancer and is typically administered as external beam radiotherapy followed by intracavitary brachytherapy. In Japan, center shielding is used in external beam radiotherapy to shorten treatment time and reduce the doses delivered to the rectum or bladder. However, it has several challenges, such as uncertainties in calculating the cumulative dose. Recently, external beam radiotherapy has been increasingly performed with intensity-modulated radiotherapy, which reduces doses to the rectum or bladder without center shielding. In highly conformal radiotherapy, uncertainties in treatment delivery, such as inter-fractional anatomical structure movements, affect treatment outcomes; therefore, image-guided radiotherapy is essential for appropriate and safe performance. Regarding intracavitary brachytherapy, the use of magnetic resonance imaging-based image-guided adaptive brachytherapy is becoming increasingly widespread because it allows dose escalation to the tumor and accurately evaluates the dose delivered to the surrounding normal organs. According to current evidence, a minimal dose of D90% of the high-risk clinical target volume is significantly relevant to local control. Further improvements in target coverage have been achieved with combined interstitial and intracavity brachytherapy for massive tumors with extensive parametrical involvement. Introducing artificial intelligence will enable faster and more accurate generation of brachytherapy plans. Charged-particle therapies have biological and dosimetric advantages, and current evidence has proven their effectiveness and safety in cervical cancer treatment. Recently, radiotherapy-related technologies have advanced dramatically. This review provides an overview of technological innovations and future perspectives in radiotherapy for cervical cancer.