WalterandMiller’s TEXTBOOK OF RADIOTHERAPY
RadiationPhysics,TherapyandOncology
EIGHTHEDITION
Editedby
PaulSymonds TDMDFRCPFRCR
EmeritusProfessorofClinicalOncology,UniversityofLeicester,Leicester,UK;Honorary ConsultantOncologist,UniversityHospitalsofLeicester,Leicester,UK
JohnA.Mills PhDMIPEMCPhys
Physicist,MACS-QualityControlProvider,JamesWattHouse,Hinckley,UK
AngelaDuxbury FCRTDCRMSc
EmeritusProfessorofTherapeuticRadiography,SheffieldHallamUniversity,Sheffield,UK
©2019,ElsevierLimited.Allrightsreserved.
Firstedition1950
Secondedition1959
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Fifthedition1993
Sixthedition2003
Seventhedition2012
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SECTION1
1 Atoms,NucleiandRadioactivity, 2 ElizabethM.Parvin Introduction,2 AtomicStructure,2 Particles,2 TheAtomandtheNucleus,3 TheForces,3 ElectronEnergyLevels,4 BandTheoryofSolids,4 ImpurityBands,5 ParticlesinElectricandMagneticFields,5 ElectricFields,5 MagneticFields,5 TheLorentzEquation,5 Waves,5 TransverseandLongitudinalWaves,5 ElectromagneticRadiation,6 ContinuousSpectraandCharacteristicRadiation,7 RadioactiveDecay,8 StableandUnstableIsotopes,8 Half-life,9 AlphaDecay,9 BetaDecay,10 GammaDecay,10 ElectronCaptureandInternalConversion,11 RadioactiveDecaySeries,11 RadionuclidesofMedicalInterest,12 References,12 FurtherReading,12
2 InteractionsofIonisingRadiationWithMatter, 13 ShakardokhtJafariandMichaelWynne-Jones Introduction,13 ChargedandUnchargedParticles,13 ExcitationandIonisation,13 ElectronInteractions,14 CollisionalandRadiativeEnergyLoss,14 X-RayProduction,14 CharacteristicX-RaysandAugerElectrons,16 StoppingPowerandLinearEnergyTransfer,16 RangeandPathLength,17 PhotonInteractions,17 ThePhotoelectricEffect,17 TheComptonEffect,18 PairProduction,19 ExponentialAttenuation,19 AttenuationofPhotonSpectra,21
BeamHardening,21 EnergyAbsorption,22 Photo-NuclearInteractions,22 PhotonDepthDoseandtheBuild-UpEffect,22 KermaandAbsorbedDoseforRadiotherapy beams,24 Kerma,24 AbsorbedDose,24 UnitsofKermaandDose,25 HeavyChargedParticleInteractions,25 Protons,25 CarbonIonsandPions,25 NeutronInteractions,26 References,27 FurtherReading,27
3 RadiationDetectionandMeasurement, 28 AndrewPoynter,AndrzejKacperek,andJohnA.Mills Introduction,28 RadiationDetection,28 GasAmplificationDevices,29 ScintillationDevices,30 IdealAirIonisationChamber,30 ProtonBeamDetection,30 MeasurementandStandardisationofDose,31 DoseStandards,31 TraceabilityofMeasurement,31 StandardCalorimeter,32 TheFreeAirChamber,33 TheProtonBeamDoseStandard,34 PracticalIonisationChambers,34 Bragg–GrayCavityTheory,34 DoseDeterminationBasedonCalibrated Instruments,35 RequirementsforPracticalIonisationChambers,35 ThimbleIonisationChamber,35 PhysicalDescription,35 MeasurementofDoseandDoseRate,36 TheParallel-PlateIonisationChamber,37 TheBeamMonitorChamber,37 IntercomparisonsWithSecondaryStandard Instruments,38 StrontiumConsistencyCheckDevice,38 IonisationChamberCorrections,38 IonRecombinationLosses,38 CorrectionforAtmosphericConditions,38 ChamberStemEffect,39 PolarityEffect,39 AlternativeDoseMeasurementSystems,39 FilmDosimetry,39 SemiconductorDetectors,40 ThermoluminescentDosimetry,42 ChemicalandBiochemicalDetectors,43 FrickeDosimetry,43
CericDosimetry,44
GelDosimetry,44 FrickeGelsandFXGGels,44 PolymerGels,44
Alanine-ElectronParamagneticResonance Dosimetry,44
BiologicalDosimetry,45
BiologicalMolecules,45
GeneticStructures,45
CellsandBiologicalStructures,45 CompositeDetectorsandArrays,45 LinearDetectorArrays,45 AreaArrays,45 VolumeDetectorsArrays,46
ElectronicPortalDosimetry,46 AlternativeSystemsforProtonBeamsDose Measurement,46 References,47
4 RadiationProtection, 49 MikeDunn Introduction,49 BiologicalEffectsofRadiation,49 StochasticHereditaryEffects,49 StochasticSomaticEffects,50 NonstochasticSomaticEffects,50 DoseDescriptors,50 EquivalentDose,50 EffectiveDose,50 BackgroundRadiation,52 LegislativeRequirements,53
TheIonisingRadiationsRegulations2017,53
TheIonisingRadiation(MedicalExposure) Regulations2017,56 AdministrationofRadioactiveSubstancesAdvisory Committee,57 EnvironmentalPermitting(EnglandandWales) Regulations2016,58 HighActivitySealedRadioactiveSourcesandOrphan SourcesRegulations2005,58 ProtectiveMeasures,58 Time,58 Distance,58 Barriers,58 Contamination,59 BuildingMaterials,59 MonitoringofRadiationLevels,60 PersonalRadiationDosimeters,60 RadiationRecords,61 OtherRequirements,61 References,62
5 ImagingWithX-Ray,MagneticResonanceImagingand Ultrasound, 64 AndyRogers,CarlTiivas,andSarahWayte Introduction,64 X-RayImaging,65 OverviewofX-RayImagingProcess,65
ProductionofX-RaysforImaging,65 InformationFromAbsorptionandScattering,66 DifferentialAttenuationinthePrimaryBeam,66 ContrastMedia,66 ScatterasUnwantedBackground,66 AntiscatterGrid,66 PlanarImaging,67 FilmandScreenDetection,67 CharacteristicCurve,68
DigitalComputedRadiographyUsing PhotostimulablePhosphors,68 FluoroscopicImagingWithImageIntensifier Chain,68
DigitalFluoroscopyandRadiographyUsingSolid StateDetectors,69 AssessmentofImageQuality,69 MagnificationDistortion,69 Resolution,GeometricUnsharpnessandMovement,69 ImageSignalandNoise,70 Dose,70 TomographicImaging,70 ComputedTomographicReconstructionFrom Projections,70 PracticalConfigurations,70 DedicatedRadiotherapySystems,71 Simulator,71 ComputedTomographyVirtualSimulator,71 TreatmentVerificationSystems,71 MagneticResonanceImaging,72 OverviewoftheMagneticResonanceImaging Process,72 ProducingaSignal,72 ReturningtoThermalEquilibrium,72 ImagingSequences,73 HowContrastIsAlteredinaMagneticResonance Image,73 HowPositionalInformationIsEncodedinthe Signal,73 MagneticResonanceImagingScanners,75 Spectroscopy,76 ClinicalApplicationsofMagneticResonanceImaging inoncology,77 BrainTumours,77 BodyTumours,77 UltrasoundImaging,77 OverviewofUltrasoundImagingProcess,77 PhysicalCharacteristicsofUltrasoundWaves,77 InteractionsatInterfaces,81 AttenuationandInterference,81 UltrasoundScanners,81 ProductionofUltrasoundforImaging,81 DerivationofanUltrasoundImage,82 BrightnessModeUltrasoundImaging,82 LinearArrayUltrasoundImaging,82 IntracavitaryandEndoscopicProbes,82 HarmonicImaging,82 DynamicImaging,82
ContrastandTissueCharacteristicImaging,83 ClinicalApplicationsofUltrasoundImaging,83 GeneralImaging,83
AdvantagesandDisadvantages,83 ImagingforCancer,84 ClinicalTherapeuticUltrasound,84 References,84
6 ImagingWithRadionuclides, 85 PaulHinton Introduction,85 OverviewoftheRadionuclideImagingProcess,85 GammaCameras,86
ScintillationGammaCameras,86 Solid-StateGammaCameras,87 ImageConstruction,87 ImagingTechniques,88 PositronEmissionTomographyScanners,90 Radiopharmaceuticals,92
TheRadionuclide,92 TypeofRadiation,92 PhysicalHalf-Life,92 SpecificActivity,92 RadionuclidePurity,92 ChemicalProperties,92
TheIdealRadionuclideforImaging,92 MechanismsofLocalisation,92 ProductionandQualityControlof Radiopharmaceuticals,93 ClinicalApplications,94
BoneImaging,94
TumourImaging,94 ImagingThyroidCancer,96
CardiacImaging,96 KidneyImaging,97 InfectionImaging,98
SentinelNodeMapping,99
PositronEmissionTomographicImaging,99 Conclusions,101 References,101
7 TherapyWithUnsealedRadionuclides, 102 MatthewAldridgeandSofiaMichopoulou Introduction,102
Iodine-131intheTreatmentofThyroidDisease,103 ThyroidCancer,103
BenignThyroidDisease,105 PalliationofBonePain,105
MolecularRadiotherapyTreatmentofNeuroendocrine Tumours,106
SelectiveInternalRadiationTherapy,106
Phosphorus-32intheTreatmentofRefractory MyeloproliferativeDisease,107
IntraarticularandIntracavitaryTreatments,107 Radioimmunotherapy,107
RadiationProtection,WasteandRegulations,108 HospitalRequirements,108 Facilities,108
ComfortersandCarers,108 OutpatientTherapies,108 WasteDisposal,108 References,109
8 RadiotherapyDevicesWithKilovoltageX-Raysand Radioisotopes, 110 ClaireFletcherandJohnA.Mills Introduction,110 KilovoltageX-RayProduction,110 X-RaysFromElectrons,110 High-VoltageCircuits,110 KilovoltageX-RayCharacteristics,111 SuperficialandDeepKilovoltageMachines,111 TubeStand,112 Collimation,112 SkinandEyeShielding,112 ControlofOutput,113 CalibrationofDoseOutput,113 ContactKilovoltageMachine,113 GrenzKilovoltageMachine,113 RadionuclideCharacteristics,114 GammaEmitters,114 BetaEmitters,114 BrachytherapyandAfterloadingMachines,114 TheHighDoseRateAfterloadingMachine,116 ImplantedKilovoltageMachine,116 Beta-RayMachine,117 Gamma-RayMachine,117 RadioisotopeSource,118 BeamCollimation,118 DesignofGamma-RayTeletherapyMachines,119 Radiosurgery,120 RadiationSafety,120 CommissioningandQualityControl,120 Conclusion,120 References,121
9 BeamProduction:MegavoltageAccelerators, 122 AndrzejKacperekandJohnA.Mills Introduction,122 TheMedicalLinearAccelerator,122 LinearAcceleratorLayoutandComponents,123 X-RayBeam,124 ElectronBeam,126 LinearAcceleratorControlSystems,127 NonstandardLinearAccelerators,127 Intensity-ModulatedRadiotherapy,127 CyberKnife,127 Tomotherapy,127 Volumetric-ModulatedArcTherapy,127 StereotacticAblativeRadiotherapy,127 FlatteningFilter-FreeDoseDelivery,128 PatientAlignmentforX-RayandElectronTherapy,128 RadiationSafety,131 Acceptance,CommissioningandQualityControl,131 TreatmentRoomDesignforX-RayandElectron Protection,131
SpecialTechniquesWithLinearAccelerators,132
TheDevelopmentofClinicalProtonandHeavier ChargedParticleAccelerators,133
ParticleAcceleratorLayoutandComponents,134
BasicComponentsofaCyclotron,134
BasicTheoryofClassicCyclotron Operation,134
IonSourceOperation,135
CharacteristicsandLimitationsforTherapy,136
Synchrocyclotrons,136
AzimuthalVerticalFocussingorIsochronous Cyclotrons,136
Synchrotrons,137
Passive-ScatteredBeamsandPencilBeamScanning Beams,138
Gantries,142
TypesofProtonandIonAccelerators,143
ClinicalProtonTherapyCentres,143
ClinicalCarbonIonTherapyCentres,145 NoncircularAccelerators,145
NeutronandOtherBeams,146
FastNeutronBeamTherapy,146
BoronNeutronCaptureTherapy,146
ProtonBoronCaptureTherapy,146
PionTherapy,147
AntiprotonTherapyBeams,147
Laser-InducedProtonandParticle Beams,147
ShieldingofProtonTherapyAcceleratorsand TreatmentRooms,148
Nanoparticle-EnhancedTherapy,148
FutureDesign,149
RecordandVerifySystems,149 Conclusion,150 References,150
10 RadiationTreatmentPlanning:Immobilisation, LocalisationandVerificationTechniques, 152
AndrewPennyandPhilSharpe Introduction,152
PatientImmobilisation,153
ThermoplasticShells,153
PatientHeadShells,154
ThreeDimensionalPrinting,154
NonshellFixationSystems,154
StereotacticFrames,154
BodyImmobilisation,155
StereotacticAblativeBodyRadiationTherapy,155 Surface-GuidedRadiotherapy,155 VolumeDefinitions,155
NoncomputedTomographyContouring Devices,156 PhysicalSimulation,156 ComputedTomographySimulation,157 VirtualSimulation,157
ATypicalHeadandNeckComputedTomography SimulationProcedure,159 MultimodalityImagesforPlanning,159
PortalVerificationandImage-Guided Treatments,160 PortalImaging,160 Image-GuidedRadiotherapy,160 References,161
11 RadiationTreatmentPlanning:BeamModels,Principles andPractice, 162
MariaManiaAspradakis Introduction,162 RepresentationofthePatientforTreatment Planning,163 ThePlanningCT,163 PatientImmobilisationforTreatment Planning,164 MotionManagementinTreatment Planning,164
MagneticResonance–BasedPlanning,164 BeamModellingandDoseCalculationsforExternal MVPhotonBeamTreatmentPlanning,164 ModellingoftheSourceofRadiation,165 ModellingofDoseintheIrradiatedMedium,166 Factor-BasedApproaches,169 ConclusiononModel-BasedApproaches,170 DosePerMonitorUnitFormalism:Calculationof MonitorUnits,170 TreatmentPlanEvaluationTools,170 IsodoseDistributions,170 BeamsEyeView,171 DoseVolumeHistograms,171 OtherTools,173 TreatmentPlanningTechniquesinExternalMV PhotonBeamRadiotherapy,174 ForwardandInversePlanning,174 ForwardPlanningWithStandardBeam Arrangements,174 Forward-PlannedIntensity-Modulated Radiotherapy,180 InversePlanning,181 SpecialisedTechniquesWithMVPhotons,183 ElectronTherapy,185 DoseCalculationsforElectronBeams,185 EnergyandDepth-DoseCharacteristics,185 Penumbra,186 StandoffandStandin,186 PatientContourEffects,186 Heterogeneities,187 FieldMatching,187 SpecialisedTechniquesWithElectrons,187 KilovoltagePhotonTherapy,188 DifferencesBetweenKilovoltageandElectron Therapy,188 ProtonandHeavy-IonTherapy,188 QualityAssuranceinTreatmentPlanning,189 TreatmentPlanningSystemCommissioningand PerformanceTesting,189 Plan-SpecificQualityAssurance,190 References,191
12
Networking,Data,ImageHandlingandComputing inRadiotherapy, 193
JohnSage Introduction,193 History,193
BenefitsandHazardsofComputerisation,193 Networking,194
LinkLayer:PhysicalInfrastructure,194
NetworkLayer:Addressing,194
TransportLayer:SendandReceive,195
ApplicationLayer:TheProgram,195 NetworkSecurity,195
DICOM,195
DICOMDataObjects,196
RadiotherapyData,197
DataStorage,197 ImageQuality,197
RadiotherapyDataTypes,197
DataBurden,198 DataSecurity,198 SoftwareDevelopment,199 Conclusion,199 References,199
13 QualityControl, 200 JohnA.MillsandPhilSharpe Introduction,200
TheQualityControlRequired,200 CommitmenttoQualityControl,201 Safety,PositionandDose,201 Frequency,TolerancesandFailureTrends,201 MeasurementandUncertainty,201 NullHypothesis,202 CombiningVariancesandTolerances,202 SettingaTolerancetoAchieveaPerformance Level,202 PerformanceImprovement,202 MaintenanceandCatastrophes,203 Long-Term,Short-TermandImmediate Monitoring,203 ImmediateMonitoring,203 Long-TermMonitoring,203 Short-TermMonitoring,203
TheRadiotherapyProcess,203 Acquisition,204 Analysis,204 Delivery,204
TheNeedforPatient-SpecificQualityControl,204 TheRadiotherapyTechnology,204 PlanningImaging,204 VirtualSimulation,204
DosePrediction,205
KilovoltageMachines,205
AfterloadingBrachytherapyMachines,205 MegavoltageMachines,205
PatientPositioning,205 TreatmentVerification,205
ComputerSystemsandNetworking,205 MeasurementEquipment,205 PracticalPatient-SpecificQualityControl,206 PracticalMethods,206 Phantom-BasedMeasurements,206 DosimetricArrays,206 GammaIndex,206 IndependentSoftwareVerification,207 SecondaryTreatmentPlanningSystem,207 Patient-SpecificQualityControlImplementation,207 GettingThingsinBalance,207 QualityControlSchedulingforMegavoltage Machines,207 Conclusion,208 References,208
14 QualityManagementinRadiotherapy, 209 JillEmmerson,KarenWaite,andHelenBaines Introduction:WhatisQuality?,209 HistoryofQualityinRadiotherapy,210 QualityManagementSystems,210 1.CustomerFocus,210 2.Leadership,211 3.EngagementofPeople,211 4.ProcessApproach,211 5.Improvement,211 6.Evidence-BasedDecisionMaking,211 7.RelationshipManagement,211 TheISO9000Standard,212 Clause4ContextoftheOrganisation,212 Clause5Leadership,213 Clause6Planning,213 Clause7Support,213 Clause8Operation,213 Clause9PerformanceEvaluation,214 Clause10Improvement,214 TheRadiotherapyProcess,214 AnIntegratedApproachtoQualityandOther Initiatives,214 QualityintheNationalHealthService,214 RiskManagement,214 ClinicalIncidents,216 Audit,217 Patient-FocussedCare,220 ImplementationofNewTechnologyandNew Techniques,221 Conclusion,222 References,222
SECTION2
15 EpidemiologyofCancerandScreening, 226 KatieSpencer,DavidHole,PaulSymonds,andEvaMorris TheCancerProblem,226 CancerintheUnitedStates,226 CancerinEurope,227
EpidemiologyofCancer,227
Terminology,227
SurvivalandCureinCancer,227
OutcomeofPalliativeCare,228
EpidemiologyandThePreventionofCancer,228
CriteriaforCausality,228
AetiologyandScreening,228
LungCancer,228
ColorectalCancer,230
Breast,230
Stomach,232
Prostate,232
Cervix,232
Oesophagus,233
Melanoma,233
HeadandNeck,233
Lymphoma,234
Leukaemia,234
ReducingtheRisksofDevelopingCancer,235
ReducingTobaccoSmoking,235
ModifyingAlcoholConsumption,236
HPVVaccination,236
UltravioletLight,236
OccupationalExposure,236
Diet,237
IonisingRadiation,237
Pollution,237
Chemoprevention,237
Conclusion,238
FurtherReading,238
16 BiologicalandPathologicalIntroduction, 239
JohnR.GoepelandAbhikMukherjee
Introduction,239
Growth:Proliferation,DifferentiationandApoptosis, 239
GrowthDisorders,239
Neoplasia,240
BenignandMalignantNeoplasms,240 Carcinogenesis,240
Initiation,240
Promotion,240
Progression,240
ClinicalCancer,241
OncogenesandTumourSuppressorGenes,241
Defectiveapoptoticmechanisms,241
BloodVessels,241
PhysicalAgents,242
Chemicals,242
VirusesandCancer,243
ImmunityandCancer,243
InjuryandCancer,243
PrecancerousLesions,243
FieldChange,244 NaturalHistoryandSpreadofCancer,244
LocalInvasion,244
Metastasis,245
FunctioningTumours,246
CauseofDeathfromCancer,246 StagingofCancers,246 TNMClassification,246 HistologicalGrading:Differentiation,247 LimitationsofGrading,248 GrowthRateofCancers,248 SpontaneousRegressionofCancer,248 ClassificationofNeoplasms,248 UndifferentiatedTumours,249
CurrentAdvancesinPathologyGuidingPatient Management,251 FurtherReading,252
17 Molecular,CellularandTissueEffectsof Radiotherapy, 253
GeorgeD.D.JonesandPaulSymonds Introduction,253 IonisingRadiation,FreeRadicalGeneration, SubcellularRadiogenicDamage,253 Recovery,DNADamageRepairandDamage Signalling,255 Recovery,255 Double-StrandBreakRepairandDamage Signalling,255 EpigeneticRadiationSignallingMechanisms,255 Radiation-InducedCellKilling,257 TumourHypoxia,OxygenEffectand Reoxygenation,257 TheCellCycleandSensitivitytoIrradiation,259 PatternsofCellDeathAfterIrradiation,259 ModelsofRadiationCellSurvival,260 RadiationEffectsinNormalandMalignant Tissue,261 AcuteResponsesofNormalTissue,261 SubacuteReactionsofNormalTissue,261 TheEffectofRadiotherapyonTissues,261 TheToleranceofNormalTissues,261 Retreatment,262 ResponseofTumourstoRadiation,262 OverallTreatmentTime,262 ModificationofFractionationPatterns,262 OtherRadiationModalities,262 HeavyParticleRadiotherapy,262 Drug–RadiotherapyCombinations,263 FutureTrends(andPitfalls),263 NewTechnologies,263 MolecularStudies,263 FurtherReading,264
18 PrinciplesofManagementofPatientsWithCancer, 265 PaulSymondsandAngelaDuxbury Introduction,265 FactorsGoverningClinicalDecisions,266 TumourFactors,266 PatientFactors,267 TreatmentModality,267 SupportServices,269 PalliativeCare,270
PainControl,270
NauseaandVomiting,271 ContextofCare,271
FurtherReading,271
19 ChemotherapyandHormones, 272
AnneL.Thomas
Introduction,272
GeneralIndicationsforChemotherapy,272 DevelopmentandTestingofAnticancerAgents,272 PhaseIStudies,273 PhaseIIStudies,273 PhaseIIIStudies,273 AssessingTumourResponses,273
TheEvaluationofTargetedTherapies,273 PrinciplesofCytotoxicTherapy,273 DrugResistance,274
SelectionandSchedulingofChemotherapyAgents, 274
High-DoseChemotherapy,274 RouteofAdministration,274 SideEffectsofChemotherapy,275 ClassificationofCytotoxicDrugs,275 AlkylatingAgents,275 Antimetabolites,275 MitoticInhibitors,278
TopoisomeraseInhibitors,279 Miscellaneous,279
Hormones,280
TargetedTherapies,281
EpidermalGrowthFactorReceptor,282
SignallingThroughRAS-RAF-ERK(MAPK)and PI3K-AKT,282
VascularEndothelialGrowthFactorSignalling Pathway,282
ProteasomeInhibitors,282
Poly(ADP-Ribose)PolymeraseInhibitors,282
CDK4/6Inhibitors,283 Immunotherapy,283
TherapeuticAntibodies,283
ImmuneCheckpointInhibitors,283 FurtherReading,284
20 SkinandLipCancer, 285
CharlesKellyandPaulSymondsand CliffLawrence
Introduction,285
KeratinocyteSkinTumours,285
Aetiology,285
BasalCellCarcinoma,287
SquamousCellCarcinomaoftheSkin,289
CanceroftheLip,289
Keratoacanthoma,289
TreatmentofNonmelanomaSkinCancer,290
RadiotherapyforKeratinocyteSkinCancers,292
ElectronBeamTreatment,293
ElectronBackscatter,293
SuperficialX-RayTreatment,293
ComparisonofOutcomeforDifferentModalitiesin theTreatmentofBasalCellCarcinomas,296 Melanoma,296 Aetiology,296 SubtypesofMelanoma,296 Diagnosis,297 MelanomaTNMStaging,297 StageandPrognosis,297 ManagementofMelanoma,300 AdjuvantTreatmentforMelanoma,301 ManagementofRecurrentorMetastatic Melanoma,301 SideEffectsofImmunotherapy,302 RoleofRadiotherapyinMalignantMelanoma,302 CutaneousLymphomas,303 MerkelCellTumours,303 SkinSarcoma,303 KaposiSarcoma,305 SkinAppendageTumours,305 FurtherReading,306
21 HeadandNeckCancer GeneralPrinciples, 308 ChristopherD.Scrase Introduction,308 Demographics,308 Aetiology,308 PreventionandEarlyDiagnosis,310 TumourTypes,310 Presentation,310 Investigation,310 Nutrition,311 Dentition,311 IndicationsforRadiotherapy,311 DefinitiveRadiotherapy,311 PostoperativeRadiotherapy,311 PalliativeRadiotherapy,311 RadiotherapyPlanning,312 Immobilisation,312 TargetVolumes,312 DefinitiveRadiotherapy,312 PostoperativeRadiotherapy,313 RadiotherapyTechnique,313 ConformalRadiotherapy,313 IntensityModulatedandImageGuided RadiotherapyinHeadandNeckCancers,313 DoseandFractionation,317 DefinitiveRadiotherapy,317 PostoperativeRadiotherapy,318 ChemotherapyinHeadandNeckCancer,318 ConcurrentChemotherapyandDefinitive Radiotherapy,318 ConcurrentChemotherapyandPostoperative Radiotherapy,318 InductionChemotherapy,318 ChemotherapyinthePalliativeSetting,318 ToxicityofTreatment,319 AcuteToxicity,319
LateToxicity,320
FutureDevelopments,320
Immunotherapy,320 FurtherReading,320
22 Sino-Nasal,Oral,LarynxandPharynxCancers, 322
ChristopherD.ScraseandPaulSymonds
Nasopharynx,323
Anatomy,323
IncidenceofNasopharyngealTumours,323
StagingSystemforNasopharyngealTumours,324
Aetiology,PathologyandLymphaticSpread,324
SignsandSymptoms,324
DiagnosisandStaging,324 Treatment,324
RadiationTechnique,325 Complications,325 Follow-up,325 Results,326
NoseandNasalCavity,326
Anatomy,326
Incidence,328
StagingSystem,328
Aetiology,PathologyandLymphaticSpread,328
SignsandSymptoms,328
DiagnosisandStaging,328
Treatment,328
Complications,330 Results,330
ParanasalSinusTumours,330
Anatomy,330
IncidenceofParanasalSinusTumours,330
StagingSystemforParanasalSinusTumours,330
Aetiology,PathologyandLymphaticSpread,331
SignsandSymptoms,331
DiagnosisandStaging,332
Treatment,332
Complications,332 Follow-up,333 Results,333
LipandOralCavityCarcinoma,333
Anatomy,333
IncidenceofOralCavityCarcinoma,333
StagingSystemforOralCavityandLipCarcinoma (TNM,8thEdition),333
Aetiology,PathologyandLymphaticSpread,334
SignsandSymptoms,334
DiagnosisandStaging,335
TreatmentLipCancers,336
RadiotherapyTechnique,337
RadiotherapyTechnique,338
Follow-up,338
ResultsofTreatment,338
OropharyngealCarcinoma,338
Anatomy,338
StagingSystemofOropharyngealTumours,339
Aetiology,PathologyandLymphaticSpread,339
SignsandSymptoms,339
DiagnosisandStaging,340 Treatment,340
RadiationTechnique,340 Complications,342
Follow-up,342 Results,342
Larynx,342
Anatomy,342
IncidenceofLaryngealCancer,343
StagingSystemforLaryngealCancer(TNM,8th Edition),343
Aetiology,PathologyandLymphaticSpread,344
SignsandSymptoms,344
DiagnosisandStaging,344
Treatment,345
GlotticCancers,345
ComplicationsofTreatmentforEarlyLaryngeal Cancer,345
ResultsofTreatment,348
HypopharyngealCarcinoma,348
Anatomy,348
IncidenceofHypopharyngealTumours,348
StagingSystemofHypopharyngealTumours (TNM,8thEdition),348
Aetiology,PathologyandLymphaticSpread,348
SignsandSymptoms,348 DiagnosisandStaging,348 Treatment,348
RadiotherapyTechnique,348 Complications,351 Follow-up,351 Results,352
FurtherReading,352
23 ThyroidCancer, 353
CharlesKellyandPaulSymonds IntroductionandEpidemiology,353 Anatomy,353
AetiologicalFactors,353
Presentation,DiagnosisandPatientPathway,354 DifferentiatedThyroidCancer,355
ManagementofDifferentiatedThyroid Cancer,356 Surgery,356
RadioiodineAblation,357
Thyroglobulin,358
ManagementofHypocalcaemia,358
ManagementofLocoregionalRecurrence,358 MetastaticDisease,358
MedullaryThyroidCancer,358
AnaplasticThyroidCancer,359
ThyroidLymphoma,359
ThyroidSarcoma,359
HurthleCellCarcinoma,359
ExternalBeamRadiotherapyforThyroid Cancer,359
AsAdjuvantTreatment,359
PalliativeHighDose,360
LowDosePalliation,360
RadiotherapyforThyroidLymphoma,362 Follow-UpPolicyforThyroidCancer Patients,363 FurtherReading,363
24 GastrointestinalCancer, 364
SomnathMukherjeeandMariaHawkins CanceroftheOesophagus,364 Epidemiology,364
AetiologyandPathology,365
RiskFactorsforSquamousCellCarcinomas,365 RiskFactorsforAdenocarcinoma,365 Anatomy,365 ClinicalManifestations,365 DiagnosticEvaluation,365 Therapy,366
RadicalRadiotherapy,366 DefinitiveChemoradiation,366 NeoadjuvantChemoradiation,366
AdjuvantRadiationorChemoradiation,367 PalliativeRadiotherapy,367 RadiationTherapyTechniques,367 Chemotherapy,369 OtherTreatments,369
OesophagogastricJunctionalTumours,369 Summary,369
CanceroftheStomach,369 Anatomy,369 Epidemiology,369 Aetiology,369 Pathology,369 ClinicalFeatures,370 Staging,370 Management,370 RadiationTechniques,371
PalliativeTreatmentsinAdvanced/Metastatic GastricCancer,371 Summary,371
Pancreas,371 Anatomy,371
IncidenceandEpidemiology,372 Pathology,372
DiagnosticEvaluationandImaging,372 Therapy,372
HepatocellularCarcinoma,375 Epidemiology,375 Symptomatology,375 DiagnosticsandClassification,375
GeneralManagementPrinciples,375 SurgicalTherapy,375 LiverTransplantation,375 LocoregionalTreatments,375 SystemicTherapyandMolecularlyTargeted Agents,376
RadiationTherapy,376 PrinciplesofRadiationDelivery,376 FuturePerspectives,377 BiliaryTractCancers,378 PrinciplesofRadiotherapy,378 CanceroftheColonandRectum,378 Epidemiology,378 Aetiology,378 HistopathologyandClinicalFeatures,379 PretreatmentStagingEvaluations,379 StagingSystems,379 ColonCancer TreatmentPrinciples,380 ManagementofAdvancedColorectal Cancer,380 Third-LineOptions,380 RectalCancer TreatmentPrinciples,381 OrgansatRisk,381 AnalCancer,382 EpidemiologyandAetiology,382 Anatomy,382 Histopathology,382 ClinicalFeatures,382 Treatment,383 References(Oesophagogastric),386 References(Pancreas),386 References(hepato-biliary,colo-rectalandanal cancer),386
25 TumoursoftheThorax, 388 MichaelSnee LungCancer,388 Pathology,388 Symptoms,388 DiagnosisandStaging,389 SystemicTreatmentforNonsmallCellLung Cancer,394 Chemotherapy,394 TargetedTherapy,395 ImmuneTherapy,395 SmallCellLungCancer,395 NeuroendocrineTumours,396 Mesothelioma,396 Symptoms,397 Diagnosis,397 PathologyandNaturalHistory,397 Management,397 Conclusion,398 FurtherReading,398
26 BreastCancer, 399 IanKunkler Anatomy,400 LymphaticDrainage,400 Pathology,400 Epidemiology,400 Aetiology,400 DuctalandLobularCarcinomaInSitu,402 InvasiveBreastCancer,402
MolecularClassificationofBreastCancer,402
MultidisciplinaryManagementofBreastCancer,402 Diagnosis,403
ClinicalAssessment,403
BreastUltrasound,403
MagneticResonanceImaging,404
PositronEmissionTomography,404
ObtainingaHistologicalDiagnosis,404 Staging,404
StagingInvestigations,405 ManagementofDuctalCarcinomaInSitu,406
RoleofPostoperativeRadiotherapyforDuctal CarcinomaInSitu,407
PrognosticandPredictiveFactorsforInvasiveBreast Cancer,408 Stage,408
Age,408
TumourSize,408
AxillaryNodeStatus,408
HER2/neuStatus,409
LymphovascularInvasion,409
PrognosticIndices,409
HormonalReceptorStatus,409 Ki67,409
MolecularSubtype,409
GeneProfiling,409
EndocrineTherapy,409
MastectomyorBreastConservation,410 ManagementoftheAxilla,411 RegionalNodalIrradiation,411 IndicationsforInternalMammaryIrradiation,413
PostoperativeRadiotherapy,413 TargetVolumeandTechniquesforLocoregional Irradiation,416
ComputedTomographySimulation,416 IntensityModulatedRadiotherapy,416 ShoulderField,417
NeoadjuvantTherapy,417
AdjuvantHormonalandCytotoxicTherapy,425 Rationale,425
WhoBenefits?,426
AdjuvantEndocrineTherapy,426
AdjuvantTamoxifen,427
AromataseInhibitors,427
AdjuvantHormonalTherapyAfter5Yearsof Tamoxifen,428
ToxicityofTamoxifen,429
TamoxifenPlusChemotherapy,429
AdjuvantOvarianSuppression,429
Adjuvant/NeoadjuvantCombinationChemotherapy (Polychemotherapy),429
NeoadjuvantChemotherapy,429
PostoperativeAdjuvantChemotherapy,430 HER2PositiveBreastCancer,430
TripleNegativeBreastCancer,434
AdjuvantChemotherapyinOlderPatients,434 ManagementofLocallyAdvancedBreastCancer,434
ClinicalFeatures,434 Diagnosis,434 PrinciplesofManagement,434 RoleofSurgery,434 ChoiceofSystemicTherapy,434 HormonalTherapy,435
LocoregionalTherapy,435 TargetVolume,435 Technique,435
DosageandFractionation(Radical),435 LocoregionalPalliativeRadiotherapy,435 Technique,435 Dose,435
BoneMetastases:PreventionandTreatment,435 PalliativeRadiotherapyforBoneMetastases,436 PalliativeSurgery,436 PrinciplesofManagement,436 MedicalManagementofAdvancedandMetastatic Disease,436 MenopausalStatusandHormoneReceptor Status,436 SitesofMetastasesandImpactonManagement,437 CytotoxicTherapy,437
MorbidityofChemotherapy(Adjuvantandfor MetastaticDisease),440 BoneMarrowInvolvement,440 GrowthFactorSupport,441
ClinicalOutcomesinEarlyandAdvancedMetastatic BreastCancer,441 Follow-Up,441
Follow-UpAfterBreast-ConservingTherapy,442 Follow-UpAfterMastectomy,442 BreastCancerinPregnancy,442 BreastCancerinMales,443 FurtherReading,443
27 GynaecologicalCancer, 444
ChristopherKentandPaulSymonds Anatomy,444
IncidenceofGynaecologicalCancer,444 CarcinomaofCervix,444
CausesofCervicalNeoplasia,444 PathologyofCervicalCancer,444 SymptomsandInvestigationsofCervical Cancer,445
Treatment,448
TreatmentofStageII–IVa,449 FutureTrends,451 CarcinomaofEndometrium,452 Pathology,453 RoutesofSpread,453 Treatment,453
PostoperativeRadiotherapy,453 FutureTrends,454
SarcomasoftheUterus,454 CanceroftheOvary,454 Aetiology,454
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They resumed their march toward the palace. His ears keenly alert for sounds of pursuit, Robert, too, fancied several times that he heard cautious footsteps following in the distance; but he finally concluded that what he heard was nothing more than the countless rustling echoes from their own footsteps.
At last they reached a winding stairway. Up this they followed Dyarkon till it brought them to another level stretch of paving.
At a command from the emperor the guard stopped and fumbled along the base of the right wall. A door in the masonry swung outward. Through this they all followed quickly, closing the door behind them.
They now stood within another passage exactly like the first, but running at right angles to it. Was it imagination that caused Robert to believe he heard a scurry of footsteps along the passage they had just quit?
“Did you hear?” murmured the princess, clutching Robert’s arm. He nodded. Then he was right. They had just quit the other passage in time!
The little procession moved on again. Another short flight of stairs brought them to a stop before a blank wall at the end of the passage. Here Dyarkon repeated his former performances and the wall opened.
A brilliant stream of sunlight burst upon them. The abrupt contrast with the dim glow of the passage all but blinded them for a few seconds.
An involuntary exclamation burst from Robert’s lips. The Sphere rested within fifty feet of them! They were standing inside the broad wall of the palace courtyard!
Instantly his mind formed a plan of action. They would make a dash for the Sphere. Once safely inside they could rise quickly and observe the actions of the crowds. Then they could lay their plans at leisure.
Rapidly he outlined his plan to the others, who acquiesced at once. If their pursuers had already reached the palace they had not a moment to lose. The courtyard was yet closer.
Hakon was able to stand, though his wounds had left him pitifully weak. Dyarkon and the professor now assisted him while Robert hurried ahead to open the trap-door entrance into the Sphere.
As they emerged from the wall a loud outcry greeted them. Without stopping to ascertain its source they hurried toward the Spherewith all possible speed. Fortunately the trap operated readily, and a few seconds later they were all safely shut within.
The outcry was now explained. Into the courtyard from the palace poured a score of nobles with drawn sabers, shouting for them to stop.
Robert jerked the control over. The Sphere leapt from the ground with such sudden force that all except Robert and the staunch Dyarkon were thrown to the floor. A minute later they were soaring far above the heads of their late pursuers.
“Phew! Close shaves are getting to be our specialty,” exclaimed Robert, recovering his breath for the first time in many minutes. “Now for our observations and conference.”
He checked the Sphere’sascent and turned to the others.
Zola was already busily binding her father’s wound. Professor Palmer had just brought her some water and a supply of bandages from the first-aid chest. Fortunately, though Hakon was weak from loss of blood, his wound was found not to be serious.
Hakon was staring intently groundward from his position by a window. Following his gaze, Robert saw a dense mob round the palace. Even at this height he could hear the Martians’ cries faintly. Evidently the rebel noblemen had succeeded well in working the masses up in revolt.
Sadly Hakon viewed the disorder below. It was now clear that it would not be safe for him to return.
“Let us all go to Earth, my dear father,” said Zola. “There we can be happy together.”
The fugitive ruler pondered for many minutes, while the others maintained a respectful silence. Finally he sighed resignedly. A faint smile played over his countenance as he turned to his daughter.
“Ah, my dear, I was a very foolish old man to think of letting you go alone. We shall, as you say, be far happier together. We shall have riches and contentment in this world of Robert’s—if, indeed, he and Professor Palmer will share a little of their fortune with us.” He smiled as he nodded toward the bullion stacked on the chamber floor.
“You are the spokesman, Robert,” chuckled the professor.
“The treasure is yours and Zola’s, sire, now that you are with us,” said Robert.
“I have given it to you and Professor Palmer, my boy, and it remains yours, except for what small portion you might wish to assign me—and Dyarkon, if he decides to go with us. As for Zola, she will share with you as your bride. What say you, Dyarkon—do you wish to go with us?”
“Oh, sire, I shall go if you desire it; but I was to have been married shortly. My heart is there.” He pointed below.
“Then you shall be permitted to return, my man. Accept this, my present to your bride; and may you have great happiness.” He handed the guard a string of beautiful emeralds which he had been wearing.
The faithful Martian was speechless with gratitude.
“I suggest, then, that the treasure be divided into four equal parts,” said the professor, presently; “one quarter for each of us. There is sufficient wealth here to make every one of us overwhelmingly rich on Earth.”
So it was agreed.
The question of provisions was the next consideration. At Hakon’s orders, large quantities of evaporated fruits and vegetables had previously been placed within the cupboards of the Sphere. A goodly quantity of the Sphere’s original supply of food tablets, etc., remained. Fortunately, too, the oxygen tanks contained enough gas to purify the air in the Spherefor a long while. It only was necessary to replenish their water supply, when they could also leave Dyarkon.
The latter task was not so easy as it sounds. For there are no convenient, open streams on Mars. They must either chance landing
at some power station or farm, or fly to one of the poles and there obtain water from one of the giant reservoirs. The elements at the nearest pole being very treacherous at this season, it was decided to chance a visit to some farmhouse.
A hurried trip was accordingly made to a small farm, a sufficient distance from the scene of the rebellion to be reasonably safe. Here the astonished farmer, who had not yet heard of the rebellion and who did not even recognize the emperor and the princess, eagerly helped these distinguished visitors to fill the water tanks of the mysterious Sphere. This the farmer had heard of, and both he and his wife gazed upon it with mingled wonder and dismay. Afterward they followed it with their eyes until it had passed beyond their vision. This farmer, and his wife and Dyarkon, had the distinction of being the persons on Mars who last saw their emperor; though the two first named did not know this till Dyarkon presently told them.
After the filling of the water tanks, Robert steered the Sphere straight toward the distant pale star which he and Professor Palmer knew was the Earth. Despite their anticipation and resignation, Zola and her father gazed back upon their erstwhile world in silent awe, and not without some sadness, long after it had ceased to be more than a mere ocher and rose disk.
Through the eternal night sped the infinitesimal world with its population of four. And through the long hours of Robert’s watches, Zola was at his side always. Their love was as an immortal thing, born of space and eternity. Hand in hand they fled across the universe to their future world of promise.
Profiting by their previous experience with gravitation, or rather, an absence of gravitation and stabilization, Robert and the professor properly manipulated the disk and gyrostats on this trip, avoiding the danger which had so nearly proved their undoing before. Robert prevented also the recurrence of another unpleasant experience, by cutting short pieces of stout cord, one for each of them, and particularly cautioned Zola and her father to tie them about their bodies at night and secure the other end to a rung or some other stationary object at a safe distance from the whirling gyrostats.
It was not long after that they had a taste of air-floating, and the cords proved their worth. This sensation, the continued sunshine out of a black sky and other phenomena, were all new to Zola and her father. The time passed rapidly.
A deck of playing cards was got out and Hakon and Zola were initiated into the mysteries of the Earthmen’s card games, which they learned readily and seemed to enjoy keenly. They then proceeded to show Robert and Professor Palmer some of their own games. These, being played with cards not greatly different from our own, were easily adapted to the cards they were using. In fact, one of their games, called Agahr, was virtually identical with our own simple game of casino.
So it did not seem long ere they were within a day’s journey of the Earth. Not a single mishap had delayed their progress so far. Barring the unexpected, they should be but a day longer in returning than the period covered by the trip to Mars, in spite of the considerably increased distance between the two planets by this time. Nearly three months had elapsed since the departure from the Earth.
As the Earth’s disk expanded before their eyes, Robert pointed out to Zola and Hakon the outlines of the continents and oceans, the mountain ranges and rivers. Their genuine wonder and delightful anticipation were a source of keen enjoyment to both the professor and Robert.
“It surpasses my wildest imagination to vision an expanse of water so vast that one can not see its boundaries!” exclaimed Hakon, excitedly. “I can scarcely contain myself till we shall actually see these wonders with our own eyes.”
“And think, Father, of the great forests of trees where one can really get lost; the mysterious clouds in the sky; the rushing rivers and waterfalls! Oh, how could I have thought of letting you stay away from all this! How happy we can be, can’t we, Robert?”
“Indeed we can, sweetheart,” he replied, with a feeling that his measure of delight was far more than he deserved.
Closer, closer drew the big world—his world and hers. Its great disk swelled and swelled, until it was no longer a disk but a vast expanse stretching away in all directions.
Robert had reduced the Sphere’s speed until they approached the surface, now less than fifty miles away, at about the speed of a fast passenger train. As they drew closer he reduced their speed still further. A big cloud bank obscured their view of the Earth’s surface now, but he knew that they were above the Atlantic. He had already given the Sphere the spin of the swiftly revolving Earth, before entering its envelope of atmosphere. They now drifted serenely, high above the clouds.
As they slowly drew near the cloud bank, Zola made a natural mistake of thinking it the ocean, till Robert told her different. Her astonishment and delight were great as they plunged through the fluffy mist and emerged above the water. A big sea was running, and
Robert permitted the Sphere to drop within a hundred yards of the tall crests.
The continual rolling of the water mystified Hakon and Zola. This was explained to them with some difficulty. Robert opened two of the Sphere’s ports, for the first time since leaving Mars. They all filled their lungs gratefully with the keen, salty air as it blew in upon them. The main force of the gale was not felt, however, because the Sphere was being driven before it. Once an eccentric gust sucked the Sphere down abruptly. A mountainous wave, rearing hungrily toward the big metal ball, slapped forcibly against it, causing it to rebound high into the air with a suddenness that upset everyone. After that Robert kept a safe distance above the seething waters.
For a while they scudded swiftly along under the hypnotic spell of the restless sea. Its hissing turbulence was a source of continual awe and wonder to their guests. Finally Robert closed the ports and sped the Spheretoward the Jersey coast.
It was in the early afternoon when they passed over the coast line. Here their appearance was first noted and news of the Sphere’ssafe return flashed all over the world. Later, as they sailed over New York, a droning of many whistles heralded their arrival, while a blimp, a big seaplane, and several airplanes glided and cavorted over, under and round them.
“Sphere ahoy!” shouted one venturesome chap, a reporter on the Times, as he whizzed by, a dozen feet away, in a two-passenger airplane. “What news?”
But the drone of his engine drowned a possible answer as the distance between them widened rapidly.
Leaving Manhattan, Robert steered the Sphere toward L—- and Professor Palmer’s estate. This was at the latter’s request, and in response to his cordial invitation to Robert and both their guests to make their home with him for the present.
Their arrival at the Palmer estate found the place already overrun with reporters and photographers in anticipation of their return there. Even the resourceful Henry could not stem the tide. Motion
pictures of them all were run off and rushed to headquarters for early projection upon the silver screen all over the world.
Hakon, and Zola, more charming than ever, both accepted the situation with jolly good nature. Praises of the beautiful maiden from Mars were many, and their sincerity was reflected in the headlines and articles which appeared as by magic in the afternoon papers throughout the country the very day of their arrival.
The party rested at the Palmer estate for several days. Many were the delightful strolls which Robert and Zola took in the lovely grounds. The soft, luxuriant grass under foot, the tall trees, the beautiful shrubbery and flowers were as a fairyland to the princess, with her fairy prince at her side. As for Robert, he was in a veritable seventh heaven.
The emperor and Professor Palmer, now great cronies, were constantly together. Halton never tired of the professor’s tales of the Earth’s resources, its history and people; and of our long observation of and conjectures regarding his own planet, Mars.
Negotiations were opened with a firm of expert diamond cutters in New York for the cutting and polishing of the stones brought from Mars. Their representatives, escorted by a heavy guard, arrived promptly and departed with the first valuable consignment of the rough gems.
The balance of the treasure, in bullion and stones, had been safely deposited in the vaults of three different banks for greater safety. The bullion, however, was rapidly converted into cash and deposited in equal shares to the individual credit of the four adventurers and one other person. This person was Taggert’s sweetheart, a Miss Sarah Daugherty, who had waited faithfully for the valiant reporter’s return. By mutual consent, a fifth and equal share of the treasure was allotted her. Taggert’s mother, poor woman, had not lived to see the return of the Sphere. She had contracted pneumonia and passed away a month before her son’s death. One of the first things Robert had done upon his return was to seek Mrs. Taggert and Miss Daugherty, after delivering Taggert’s notes to the Morning Chronicle with an additional report on the
events following the lion-hearted reporter’s death. He obtained the publishers’ ready consent to turn over all salaries and bonus due Taggert, to Miss Daugherty.
From the moment of their return, Robert and Professor Palmer were lionized by the world. Eminent scientists from everywhere sought interviews with them. Even the former opponent of the Palmer theories, Professor Margard, came to Professor Palmer with sincere congratulations. They were besieged by learned societies to lecture at gatherings for their enlightenment. Capitalists and promoters begged them to consider offers of enormous sums for their patents on the Sphere’sremarkable gravity-defying principles.
Construction of a huge device for flashing messages to Mars by means of reflection of the sun’s rays was commenced in the Sahara Desert. A code furnished by the emperor was to be used. Though wireless had been considered, the enormous distance was judged to be too great to make that method of communication practicable, even with the most powerful apparatus then conceivable.
“They’ll be betting on each other’s stock markets soon,” laughed Henry, when he heard of the project.
On the day of Robert’s and Zola’s wedding, the emperor presented his daughter with a magnificent, perfect ruby, which he had had set, and hung in a pendant, with the connivance of the professor. The gem was uniquely cut, similarly to what we know as table-cut. He also presented them with a packet of three remarkable stones, in the rough, which he had secretly brought with him. One of these was a black diamond of twenty-one carats; another was a white diamond of slightly larger size.
The third stone was also a white diamond, but of astounding size. It was several times larger than the famous Koh-i-noor; it even exceeded in size the Great Mogul in the rough, as it balanced at a trifle under 1,115 carats! Properly cut and polished, without the unfortunate bungling which both the Koh-i-noor and the Great Mogul had suffered, it should weigh considerably more than these two famous gems together, they weighing 106 and 280 carats respectively after their final cutting.
“It should be named,” said the professor, when shown this enormous stone. “What are you going to call it?”
“Let us call it the Ragnarok, which means ‘the twilight of the gods and the doomsday of the world’—in memory of the waning world from which it came,” suggested Robert, after some thought.
And so it was named.
The little vine-clad church in the village saw the wedding of Robert and Zola on a delightful, soft autumn afternoon a few days later. Her father gave her away, and Professor Palmer was the best man. Futile attempts at fittingly describing the glorious vision presented by the princess were attempted. But perhaps none was more apt than that ventured by the professor’s housekeeper, a kindly soul, who had helped Zola choose her dainty bridal gown and charming trousseau. “A true daughter of the gods,” was the rather surprizing expression of this normally prosaic woman.
More surprizing, however, may have been the choice of these two young beings of the scene of their honeymoon. Not a tour of Europe, nor of the natural wonders of our own great country. They simply disappeared into the great Canadian wilderness. There, if one could have followed them, they might have been discovered happily paddling a well-loaded canoe up a winding stream of still, friendly, wooded shores. Above, the clear blue sky rivaled the crystal transparency of the rippling stream. A hawk drifted across the ribbon of blue and was lost again beyond the maze of tall pines. Somewhere a woodpecker drummed stoutly upon a dead limb.
Softly, easily, the slim craft rounded a bend to the even thrust of two pairs of vigorous, willing young arms. Like the hawk, it was soon lost to view—lost in a twilight wilderness of love and peace.
[THE END]
Transcriber’s Note: This story appeared in four consecutive issues of WeirdTales magazine starting in November 1925.
*** END OF THE PROJECT GUTENBERG EBOOK THE WANING OF A WORLD
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