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Outline
Introduction

Technical

Dose calculations

Clinical
Introduction
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istory

Discovered in 1898, radium was most common

brachytherapy source
Not used today due to high þray energy
(shielding problems)
Chemical and radioactive toxicity of radium
and byproducts
Typical artificial, þray emitting isotopes used
e.g. cesium, iridium, gold, iodine

istory

Xþrays discovered before radium radium

used for treatment first

÷lexander Graham Bell 1903

Suggests encapsulation in needles for direct
insertion into cancer lesions
÷dvantages

Usually outþpatient no hospitalization

ighly conformal dose distribution and good
healthy tissue sparing

Since source is implanted less concern for

localization and target motion

Very high local doses

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Types of Brachytherapy
$ =
, in which sources are
placed into body cavities close to the tumour
volume.
$ =
, in which sources are
implanted surgically within the tumour volume.
$ _
, in which sources are
placed over the tissue to be treated.
$ =
, in which sources are
placed in a lumen.
$ =

, in which sources are
implanted into the target tissue during surgery.
$ =
, in which a single source
is placed into small or large arteries.
Types of Brachytherapy
Interstitial
‡ Surgical placement of sources within the tissue

‡ Temporary or permanent

‡ Most common application for permanent

implant of prostate cancer

‡ Other sites include: some gynecological

tumours, breast tumours and head and neck

Interstitial brachytherapy can be either

or
.

Most widely used radionuclide at the present time is iridiumþ192

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The relatively short halfþlife of iridiumþ192 (70 days) means

that a range of dose rates is inevitable. It is important,
therefore, to correct the total dose rate.

Iridiumþ192 has two advantages:

1) The source size can be small, and

2) Its lower photon energy makes radiation
protection easier than with radium or cesiumþ137

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Sources of this
radionuclide are
ideal for use with
computerþ
controlled remote
afterloaders
introduced in
1990s.

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jncapsulated sources with relatively short halfþlife can be

left in place permanently. There are two advantages for the
patient:

1) ÷n operation to remove the implant is not needed,

2) the patient can go home with the implant in place.

Iodineþ125 has been used most widely to date for permanent

implants.
The total prescribed dose is usually about 160 Gy at the periphery
of the implanted volume, with 80 Gy delivered in the first
halfþlife of 60 days.
÷ major advantage of iodineþ125 is the low energy of the photons
emitted (about 30 keV).
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÷ number of other new radionuclides are under consideration
as sources for brachytherapy that share with iodineþ125 the
properties of a relatively short halfþlife and lowþenergy photon
emission to reduce problems of radiation protection.

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Types of Brachytherapy
Intracavitary
‡ Sources placed within body cavity via special applicator

‡ Intracavitary treatments are always temporary

‡ Most common implant worldwide

‡ Most gynecological tumours of the uterine cavity and

vagina

‡ Intraluminal: sources through lumen of vessel; e.g.

bronchus, esophagus or bile duct
Types of Brachytherapy
Surface Molds
‡ Radioactive sources placed in specially
designed surface molds

‡ Molds placed on surface of target to treat

superficial tissue

‡ Less commonly used

Loading systems
Manual hot loading
‡ Initial technique with sources placed by staff directly
into patient, high dose to staff

Manual ÷fterloading
‡ Needles, catheters, or applicators inserted into tumour
‡ Confirm position, then load radioactive seeds by hand

Remote ÷fterloading
‡ ÷s above, but seeds are loaded remotely under
computer control to minimize dose to staff
Duration of treatment
Permanent implants
‡ Many radioactive sources implanted and left to decay
within patient

‡ Distribution of sources cannot change after implant

‡ Isotopes with low energy (tens of keV) and short half

lives (~days)

‡ 125I, 198÷u and 103Pd

Duration of treatment
Temporary implants
‡ Radioactive source placed near treatment site for short
time period (up to 20 minutes) then removed when
desired dose is delivered

‡ Better control of dose distribution

‡ Usually fractionated

‡ Can alter insertion in subsequent fractions

Dose Rates
Low dose rate: LDR (0.4 to 2.0 Gy/hour)
‡ Permanent, manual afterloading techniques
‡ Temporary treatments over days requiring hospitalization
‡ Most common historically
Medium dose rate (2 to 12 Gy/hour)
‡ Rarely used, pulsed dose rate (high dose rate exposed for
5 10 min / hour) ~LDR

igh dose rate:
DR (>12 Gy/hour)
‡
igh activity 10 CI 192Ir source, remote afterloading
‡ Outþpatient treatment, time ~ minutes
‡ Requires increased radiation shielding
‡ Renewed interest in brachytherapy
Technical
Sources

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Containing the radioactivity;

Providing source rigidity;

÷bsorbing any j and, for photon emitting sources,

radiation produced through the source decay.
Sources
÷lthough 226Ra was original brachytherapy source
not ideal
Characteristics
‡ jnergy of þray (shielding)
‡
alf life
‡ Toxicity
‡ Machinability
‡ Specific activity
‡ Source strength;
‡ Inverse square fallþoff of dose with distance from the
source
Brachytherapy sources

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192Iridium

Complicated þray spectrum with average energy ~

360 keV
Moderate þray energy requires less shielding than
some isotopes
Short half life means sources replaced routinely (3
months)

igh specific activity allows for small source size
(0.6 x 5 mm) with high activity (10 Ci)
Brachytherapy sources
, the
distance between the ends
of the radioactive material;

, the
distance between the actual
ends of the source;

, (mg radium
content); and
(d) , transverse
thickness of the capsule
wall, (mm Pt)
Varian (VariSource)
0.6 diameter, 5mm long iridium seed welded to
Nitinol (Ni/Ti) flexible wire

Wire mechanically drive out of afterloader through

one of 20 channels

Program range of treatment positions and dwell

times

Typically 0.5 cm step sizes (up to 20 steps)

Stepping of source

147 cm 150 cm

to machine
Operation
Source stored within unit in shielded safe
Receives command to send out source
Sends out xdummy wire to check path clear
Stepper motor drives active wire out to most
distal desired position of 1st channel
Retracts wire in planned steps and dwells at
each position for required time
Retract source completed and repeat in
other channels if required
VariSource ÷fterloader
Calibration of Brachytherapy
Sources
Specification of Source Strength
$ ÷ctivity
Number of dis/s (1 Ci = 3.7 1010 dps)
$ jxposure rate (jR) at a specified distance
NCRP recommendation, usually at 1 m
$ jquivalent mass of radium
Divide jR by the jR constant for Radium
$ ÷pparent activity
Bare point source (no filtering)
$ ÷ir kerma strength
÷÷PM recommendation

istorically source strength specified by
exposure, X [R]
Currently source strength specified by `
`
(SK)

Relating the two

SK = X(R/h) (W/e)
= X(R/h) (8.76 x 103 m2 mGy/R)
‡ (W/e) average energy absorbed per unit charge
of ionization in air (0.876 cGy/R)
j

jxposure is being phaseþout and ÷ir kerma is replacing
it.
‡

±
ard to measure output, used to calibrate sources
‡

± Calibrated against a calibrated source
± More suitable for routine work
jxposure rate calibration
NIST calibrates in air at 1m with spherical graphite
chamber

Used to calibrate well type ionization chamber

These are used for routine calibration

Recalibrated every two years at accredited dose lab

Specific to isotope of interest

÷ctivity calibration
Wellþtype chamber to measure activity and
compare to manufacturer specifications
Correct for temperature and pressure
Perform measurements at chamber sweet
spot highest dose response
agree to within 0.5%
Wellþtype ion chamber
Dose Calculations
Dose is determined by three factors
(a) Inverse square law (()
*

(b) ÷ttenuation in tissue þë

(c) Scatter in tissue

(1) Point Source:

+ ,÷- ()* þë .
Task Group þ43
Modular method of dose calculation using tabular
data as a function of position
m{
m m { m{ m

SK = air kerma strength [U = cGy cm2 hþ1]
M = dose rate constant (type of source, its construction and
encapsulation), dose rate per unit SK at 1 cm along the transverse axis
of source; M=Doserate(1, /2)/SK
G(r, ) = geometry factor (accounts for falloff of photon fluence from
source; 1/r2 for a point source
F(r, ) = anisotropy factor normalized to = /2
g(r) = radial dose function; radial dependence of scatter and absorption in
the medium along transverse axis
TG þ 43

For 192Ir, anisotropy less significant

Simplify by assuming point source
M= 1.11 cGy hþ1 Uþ1
g(r) available in tabular form

(m )
(m ) 0
m
Source Localization
Orthogonal Imaging
÷pplicator positions digitized on each film
y coordinate common to both
÷pplicator position stored as x, y, z and
corrected for magnification using known
length or geometry
Can also be done at smaller angles (stereo
shift method 20°), larger errors
Difficulties: mag factor, many coplanar
seeds and patient motion
Source Localization
Orthogonal Imaging
Orthogonal Images
P÷ image L÷T image

Tip of marker seed #7

in catheter #2
Source Localization
CT Imaging
More complex implants require CT imaging
Prostate uses up to 20 lines inserted
Implant applicators, CT image of area
Digitize applicator locations in 3D
Digitize organs at risk and define tumour
volume to be treated
Better visualization of anatomy
Increased time and transport patient to CT
Source Localization
Ultrasound Imaging
Transþrectal ultrasound allows for
visualization prostate, urethra, bladder etc
Planning ultrasound allows for generation
of preþplan
Planned needle positions referenced to grid
template sutured to patient s skin
Implant done under G÷ with ultrasound
guidance; monitor needle placement
Clinical sites
Clinical sites
Site Type Dose Dose/#fx Imaging
rate (cGy)

jndometrium Intracavitary
DR* 1800 / 3 Xþray
Cervix Intracavitary
DR* 2500 / 5 Xþray / CT
2600 / 4
Prostate Interstitial
DR 2100 / 3 CT
Interstitial LDR 14 400 US
(125I)
jsophagus Intralumenal
DR 1800 / 3 Xþray
Lung Intralumenal
DR 2100 / 3 Xþray
*previously LDR Csþ137
Carcinoma of the endometrium
~3600 cases / year (Canada); JCC 100
Standard treatment hysterectomy þ curative
Treatment to dome of vagina M recurrence
Combined with external beam radiation
Target vaginal mucosal lining
Prescribe dose to surface of cylinder
Simple application, no sedation required
Diameter conform to patient anatomy
Vaginal treatments
Cervical cancer
~ 1400 cases / year; JCC 200
Combined with external beam radiation and
chemo as curative treatment
Target vaginal fornices, cervix and
endometrium
Prescribe dose to point ÷
Tolerance dose uterine vessels cross ureter
Tandem length variable
Sedation required, sterile procedure
Uterine Cervix
Uterine Cervix
P÷ image L÷T image

Seed #7
cervical os

Rectal retractor
Uterine Cervix

Foley
catheter

ODose to bladder and rectum

Lung cancer
Surgery, external beam, chemo and brachy
Brachytherapy palliative treatment only
Obstructive lung tumours open airway
Prescribe dose 1 cm radial to catheter or to
volume
Place catheter(s) with bronchooscope under
conscious sedation
Treat multiple obstructions if necessary
Prostate cancer
~18000 cases/year
Treat with surgery, ext. radiation, brachy
Brachy limited to early stage (I and II)
disease O confined to prostate

DR implants and LDR permanent
implants used
Both require high dose to prostate volume
and sparing of urethra and rectum

DR procedure
Needles and catheters inserted into prostate with
template under US guidance
CT of volume; contouring of prostate and organs
at risk
Treatment plan created and treatment delivered
Catheters can be removed and reinserted for
subsequent fractions, or
Catheters remain in place and treatment repeated
later (Day 1: CT am treat pm; Day 2: treat am and
pm
Dose to prostate ~2000 cGy (2x10 or 3x7)
Misc. Sites
Interstitial brachytherapy can be performed
nearly anywhere
Breast tumours ‡
Brain tumours ‡

ead and neck tumours ‡
Gynecological implants ‡
Intravascular brachytherapy (restenosis)
Bile duct
Nasopharynx
Partial Breast Treatment