Lecture 5 Brachytherapy Implantation - 6-18 Final

Brachytherapy in treatment of cancer

Implantation Techniques and

Methods of Dose Specifications
GYN
Cervical cancer
Endometrial cancer
Other rare tumors (vaginal cancer, etc)

GU
Brachytherapy Course Lecture V
Prostate seed implant
Breast
Balloon brachytherapy to deliver RT to lumpectomy bed
Krishna Reddy, MD, PhD

Assistant Professor, Radiation Oncology
Other rare situations (endoluminal obstruction, etc.)
Definitions
Importance of Brachytherapy in GYN

Cancers
Brachytherapy placing radioactive material directly in or near the

target
Patterns of Care studies

Improved local control/outcomes correlate with increasing use of bachytherapy
over time
recurrences and complications are decreased when brachytherapy is used in
addition to EBRT
Intracavitary placed w/i pre-existing body cavity

Interstitial placed w/i interstices/spaces in an organ
High dose rate temporary radioactive source utilizing rate of > 0.2
Gy/min
Low dose rate source left in place for duration of treatment
ABS recommends brachytherapy must be included as a component of

definitive RT for cervical carcinoma
usually rate of 40 200 cGy/hr

May be temporary (removed after days) or permanent
ICRU 38 and ICRU 58
More Definitions
1985: ICRU Report 38 was written regarding the Dose

and volume specification as well as reporting
intracavitary Brachytherapy in GYN.
1997: ICRU Report 58 was written to generate a
guideline about the dose specification and reporting for
interstitial Brachytherapy
The aim of the report 58 was to develop a common
language that was based on the presently existing
concepts.
Temporary Implants
The radioactive sources are removed from the tissue after the
treatment is completed.
Radionuclide used have typically longer half life.
Permanent Implants
The brachytherapy sources remain in the patient indefinitely, and
they will not be removed.
Radionuclide used have typically shorter half life.
Source Delivery
Advantages of HDR vs LDR

Eliminates radiation exposure to caregivers/visitors
Shorter treatment times
HDR remote afterloadering using Ir-192 (outpatient setting)

PDR remote afterloadering using Ir-192 in an (inpatient setting)
LDR manually loaded or remote afterloading using Cs-137 and/or
Ir-192 (inpatient setting)
Prolonged bed rest is eliminated

Makes it possible to treat pts who may not tolerate long periods of isolation, and those at risk
for cardiopulmonary toxicity w/ prolonged bed rest
Less risk of applicator movement during therapy
Allows greater displacement of nearby normal tissues (by packing) potentially reduces
rectal/bladder morbidity
Possible to treat larger # of pts in institutions that have a high volume but insufficient inpatient
facilities (developing countries)
Planning basics
Advantages of HDR vs LDR
Planning temporary implants
Smaller diameter sources
The total time of implantation depends on
Reduces need for dilatation of cervix

Physically easier to insert applicator
Number of sources
Strengths (activity) of each source
Pattern of distribution of sources
Makes dose distribution optimization possible

Variation of dwell time w/ single stepping source allows infinite variation of effective source
strength /positions potentially less morbidity
Planning permanent implants,

The number of sources depends on
Their initial strength
Type of the radioisotope
Computerized treatment planning

(more to come)
ICRU 38: Guidance on combination of

brachytherapy and external beam doses
Allows the calculation of

isodose lines
Point doses can be calculated
easily
Real-time Volume based
planning
Often brachytherapy is given

as a boost to external beam
radiotherapy
If both are planned from CT
scans the dose can also be
overlaid in many treatment
planning systems
Composite dose to normal
tissues must be carefully
tracked
Commissioning of brachytherapy treatment

planning
Combination of dose distributions

Watch radiobiological differences!
1Gy EBT is not necessarily equal to 1Gy
Brachytherapy
Source entry methods (e.g. orthogonal films) - check

geometry
Source library
Source strength (apparent activity?)
Decay corrections (automatic?)
Dose calculation - check also multiple sources
dose rate dependence

fraction size
interfraction interval
Dose prescription and reporting in

interstitial brachytherapy
Prescription and reporting

There are several historic systems of prescribing
brachytherapy
ICRU report 58 (1995)

Recommendations based on
the so called Paris system
3D nature of the implant
considered
Manchester system
Paris system
Relevant reports of the ICRU

Report 38 (Gynaecological brachytherapy) - 1985
Report 58 (Dose and volume specification for reporting
interstitial brachytherapy) - 1998
Prescription and reporting
Importance of prescription systems
While prescription may vary slightly depending on the

specific clinical situation, it is always guided by current
standard of care (best practice) and current protocols
(i.e., RTOG)
Prior to availability of
computerized dose calculation, the
dose was prescribed according to
systems which were linked to
particular applicator design
Clinical experience has been
gained using these systems
Modern recommendations are
rooted in these systems
e.g. Manchester system
Optimum Placement - lateral
Intraoperative Procedure
Good applicator placement must be achieved to obtain increased local control,

survival and lower morbidity
Consider interstitial brachytherapy for pts with disease that cannot be optimally encompassed
by intracavitary appproach (vaginal narrowing, absent fornices, vaginal extension of disease)
Largest ovoid diameter that can be accommodated in the fornices without displacement should
be inserted
Tandem 1/3 of the way between S1/S2

and symphysis pubis
Tandem midway between bladder
and S1/S2
Best achieved w/ greatest curvature tandem
Conscious sedation/MAC
Pt discomfort
Ovoids should be against cervix

Use largest ovoids possible
Tandem should bisect the ovoids
Ant and post packing to displace bladder
and rectum
Seeds @ 12 & 6 oclock to verify adequate
packing
Optimum Placement AP View
Ovoids should fill the vaginal

fornices
Ovoids should be separated by
0.5 to 1 cm, admitting the flange
of the tandem
Some Basics of Dose Calculations

(ICRU)
Flange flush against cervix
Axis of the tandem should be

CENTRAL between the ovoids
In radiotherapy practice:
Volumes vary significantly
from patient to patient
No homogenous dose
distribution
ICRU 58: Dose prescription
Line
sources
Assume implant of line

sources in parallel - this
could also be the catheters
for a stepping HDR source
Calculate dose distribution in
plane orthogonal to the
source lines
Calculate dose between lines
Dm = Mean Central Dose
Dose
profiles
Prescription Dose
ICRU 58: Dose prescription
Minimum Target Dose (MTD):
The calculation points are

always in the geometrical
center between line sources
Prescribe to 85% of the
mean of these point doses
This works only if the
differences between the
dose at different points is
not too large
The minimum dose at the periphery of the CTV = Minimum
dose decided upon by the clinician as adequate to

treat the CTV (minimum peripheral dose).
MTD 90% of the prescribed dose in the Manchester
system for interstitial brachytherapy
Prescription Dose (cont..)
Prescription Dose (cont..)
Mean Central Dose (MCD) : Dm
Dose Uniformity Parameters
The minimum dose at the periphery of the CTV =

Arithmetic mean of the local minimum doses
between sources, in the central planes.
ICRU defines the following two methods for the dose

uniformity
1.
2.
The spread of the individual minimum doses used to calculate

the mean central dose in the central plane (expressed as a
percentage of the mean central dose).
The dose homogeneity index; defined as the ratio of
minimum target dose to the mean central dose.
Dose Distribution in one or more planes

through the implant
ICRU 58: dose prescription

System can be extended to
any number of sources
The minimum information needed for the dose

distribution of an implant is:
The isodose curves in at least one plane either in tabular form
or by graphical presentation
The central plane of the implant should be used, if only one
plane is chosen
Levels of priority for reporting

temporary interstitial implants
In practice one needs to report at a

minimum:
Dose to target and possible critical structure
Description of implant (sources, techniques)
Dose time pattern
Intraoperative Procedure
Good applicator placement must be achieved to obtain increased local control,
survival and lower morbidity
SOME BASICS OF APPLICATOR PLACEMENT

(IMPLANTATION) for CERVICAL BRACHYTHERAPY
Consider interstitial brachytherapy for pts with disease that cannot be optimally encompassed
by intracavitary appproach (vaginal narrowing, absent fornices, vaginal extension of disease)
Largest ovoid diameter that can be accommodated in the fornices without displacement should
be inserted
Conscious sedation/MAC
Pt discomfort
Optimum Placement AP View
Optimum Placement - lateral
Tandem 1/3 of the way between S1/S2

and symphysis pubis
Tandem midway between bladder
and S1/S2
Best achieved w/ greatest curvature tandem
Ovoids should fill the vaginal

fornices
Ovoids should be separated by
0.5 to 1 cm, admitting the flange
of the tandem
Flange flush against cervix
Ovoids should be against cervix

Use largest ovoids possible
Tandem should bisect the ovoids
Ant and post packing to displace bladder
and rectum
Seeds @ 12 & 6 oclock to verify adequate

packing
Axis of the tandem should be

CENTRAL between the ovoids
Lateral View of Optimized System

Placement
AP View of Optimized System Placement

The ovoids should fill the
vaginal fornices, add caps to
increase the size of the ovoids if
necessary.
The ovoids should be separated
by 0.5 1.0 cm, admitting the
flange on the tandem.
The axis of the tandem should be
central between the ovoids
Tandem is 1/3 of the way between

S1 S2 and the symphysis pubis.
The tandem is mid positioned
between the bladder and sacrum.
Marker seeds should be placed in
the cervix.
Ovoids should be against the cervix
(see marker seeds).
Tandem should bisect the ovoids.
The bladder and rectum should be
packed away from the implant.
Pt A
2 cm along the intrauterine tandem from the cervical os or flange of the
tandem and 2 cm laterally in the plane of the intracavitary system
Pt B
5 cm lateral from a point 2 cm vertically superior to the cervical os or flange
of the central tandem along the patients midline = 3 cm lat to pt A if in
midline = parametrial dose = 30-40% of pt A dose
Pt C
4cm lat to Pt A = side wall = 20% dose to pt A
Bladder point
posterior surface on lateral, center of AP film w/ foley w/ 7 cc radiopaque
fluid pulled down against urethra.
Rectal point
5mm behind posterior vaginal wall between ovoids at inferior point of last
intrauterine tandem source, or mid vaginal source
Vaginal Surface
Lateral edge of ovoid on AP film & mid-ovoid on lat film. If no ovoids are
used (tandem only), the vaginal surface point will be placed just lateral to
the packing at the level of the cervical os (cervical flange marking the os or
marker seeds)
S1 - S2
BL
SP
Point A (ICRU 38)
Gynecological brachytherapy
Defined as 2 cm along the intrauterine tandem in

the superior direction from the flange, and 2 cm
perpendicular to the tandem in the lateral
direction.
Point B (ICRU 38)

Defined as 2 cm along the intrauterine tandem
in the superior direction from the flange, and 5
cm lateral from the midline of the patient.
System accounts for

shift of applicator in
all directions
x
x
Prescription
Diagram of Bladder Point
Treat Point A to at least a total LDR equivalent of

8085 Gy for early stage disease
Pelvic sidewall dose recommendations

5055 Gy for early lesions
LDR
Following 45-50 Gy EBRT + 40-60 cGy/hr to a cumulative dose of 40-45
Gy.
HDR
typically prescribed in one of the following fractionation regimens - 5.5 Gy
x 5; 6 Gy x 5;7 Gy x 4
Prescription
HDR 600 x 5
Rectum <4.1 Gy / fraction
Moving forward
<70% of prescription dose
Bladder <4.6 Gy / fraction

<75% of prescription dose
EBRT + LDR Brachy, total dmax for
Small intestine 50 Gy
Rectum <70 Gy
Bladder <75 Gy
Vaginal surface <120 Gy (<140% of pt A dose)
Upper Vaginal Mucosa-120 Gy

Mid Vagina 80-90 Gy
Lower Vagina 60-70 Gy
Clinical Target Volume Definition
Clinical Target Volume Definition
Per GYN GEC ESTRO Working Group (2005)
Low Risk CTV (LR CTV)
High Risk CTV (HR CTV)
Potential microscopic spread

LR CTV = primary tumor CTV + regional LN CTV
Includes GTV, entire uterus, parametrial tissues to the pelvic sidewall, at
least 2 cm of normal vagina beyond any gross tumor, minimum of 1.5
cm around the iliac vessels (surrogate for iliac LNs), any normal or
enlarged pelvic LNs
Volume covered by EBRT
Major risk of local recurrence due to residual macroscopic disease

GTVB1 + entire cervix
Deliver total dose of 80-90 Gy
Intermediate Risk CTV (IR CTV)

Correspond to initial macroscopic extent of disease, with, at most,
residual microscopic disease at time of brachytherapy
CTV according to GTV at diagnosis
IR CTV = HR CTV + margin 0.5 to 1.5 cm
Points A and B
T&O Isodose
Syed Template used for Interstitial Brachytherapy for
GYN cases
Case 7
QUESTIONS?
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What are the different types of brachytherapy sources?

What are the different types of brachytherapy sources?

What are the advantages of HDR brachytherapy over LDR brachytherapy?

What are the advantages of HDR brachytherapy over LDR brachytherapy?

Brachytherapy in treatment of cancer

Implantation Techniques and

Brachytherapy Course Lecture V

Prostate seed implant

Krishna Reddy, MD, PhD

Other rare situations (endoluminal obstruction, etc.)

Importance of Brachytherapy in GYN

Brachytherapy placing radioactive material directly in or near the

Patterns of Care studies

Intracavitary placed w/i pre-existing body cavity

ABS recommends brachytherapy must be included as a component of

usually rate of 40 200 cGy/hr

ICRU 38 and ICRU 58

1985: ICRU Report 38 was written regarding the Dose

Advantages of HDR vs LDR

HDR remote afterloadering using Ir-192 (outpatient setting)

Prolonged bed rest is eliminated

Advantages of HDR vs LDR

Planning temporary implants

Smaller diameter sources

The total time of implantation depends on

Reduces need for dilatation of cervix

Makes dose distribution optimization possible

Planning permanent implants,

Computerized treatment planning

ICRU 38: Guidance on combination of

Allows the calculation of

Often brachytherapy is given

Commissioning of brachytherapy treatment

Combination of dose distributions

Source entry methods (e.g. orthogonal films) - check

dose rate dependence

Dose prescription and reporting in

Prescription and reporting

ICRU report 58 (1995)

Relevant reports of the ICRU

Prescription and reporting

Importance of prescription systems

While prescription may vary slightly depending on the

Optimum Placement - lateral

Good applicator placement must be achieved to obtain increased local control,

Tandem 1/3 of the way between S1/S2

Ovoids should be against cervix

Optimum Placement AP View

Ovoids should fill the vaginal

Some Basics of Dose Calculations

Flange flush against cervix

Axis of the tandem should be

ICRU 58: Dose prescription

Assume implant of line

ICRU 58: Dose prescription

Minimum Target Dose (MTD):

The calculation points are

The minimum dose at the periphery of the CTV = Minimum

dose decided upon by the clinician as adequate to