Brachytherapy I

Therapeutic Radiological Physics (Version2013 - C.

Saw)

CHAPTER 14

Brachytherapy I
Brachytherapy has been practiced since the discovery of radioactivity by

Henri Becquerel in 1896 and radium by Madame Marie S. Curie in 1898. The
prefix "brachy" is a Greek word, which literally means "short". The practice
of brachytherapy involves the placement near or implantation of radioactive
sources directly into tumors. The implantation of radioactive sources into or
placed near allows the radiation doses to be directed at the tumors while sparing
neighboring normal tissues. The unique characteristic of brachytherapy has
been its rapid dose falloff as a function of distance from the sources (inverse
square law). Other names that have been used for brachytherapy are
curietherapy or endocurietherapy. Because of the concerns for radiation
hazards, brachytherapy practice declined when x-rays machines with higher
energies around 130 kV to 200 kV were introduced in the 1930s, and then
megavoltage machines in the 1950s. The concerns of radiation hazard are the
exposures and the precautionary measures to avoid or to minimize radiation
exposures such as (a) radiation safety training to hospital personnel and
nurses, (b) keeping inventory and tracking radiation sources, (c) requiring
isolation rooms for hospitalized patients, and (d) handling of radiation
mishaps.
In the late 1960s, and particularly during the 1970s, there was a rebirth
in the use of brachytherapy. This rebirth was due in part to the (a) introduction
of artificially produced radioisotopes, (b) availability of computerized dosimetry
systems, (c) development of afterloading techniques, and (d) introduction of
remote afterloading systems. The introduction of artificially produced
radioisotopes offers radium substitutes with photon energies that are more
suitable for a particular treatment and easily handled radiation precautionary
measures. As an example, the use of iodine-125 which emits low energy
photons can be easily shielded and less hazardous compared to the products of
radium. The introduction of afterloading techniques has eliminated the
exposure to surgical nurses in the operating room. The introduction of
afterloading techniques followed by remote afterloading systems present a
source loading procedure that has virtually eliminated radiation exposures to the
444 Chapter 14: Brachytherapy I
staff and public. As such manual brachytherapy in particular, temporary

implants are rarely performed. The topic of remote afterloading systems will be
discussed in the next chapter.
The interest of this chapter is to present brachytherapy terminology,
specification of source strength, dosimetry of brachytherapy and some manual
brachytherapy procedures. Today, the dosimetry of brachytherapy follows that
of TG-43 dose calculation formalism. However, some of the brachytherapy
fundamentals such as exposure rates and Manchester system of implant
dosimetry systems still influence today’s brachytherapy concepts are discussed.
Intravascular brachytherapy which was once popular in the late 1990 for the
treatment of coronary diseases will be discussed in Chapter 18. The acceptance
test and commissioning of brachytherapy equipment including treatment
planning systems and instrumentation and radiation safety aspects of
brachytherapy will be discussed in Chapters 19 and 20 respectively.
14.1 Brachytherapy Terminology
In the early days, the practice of brachytherapy was rather simple. This
involved the direct insertion of radioactive sources into the patient. This
technique was called preloading technique (or hot loading technique). In the
afterloading technique, empty catheters or applicators are inserted into the
patient for radioactive sources loading at a later time, typically in the patient’s
room after localization and dosimetry calculations. Afterloading technique
eliminates radiation exposures during the brachytherapy procedure to (a) the
surgical staff while the applicator are being manipulated and placed in the
patient in the surgery room and also in the recovery room, (b) the transport
personnel and public at elevators or hallways while transporting the patient to
radiation oncology facility and patient room, (c) the radiation oncology staff
while performing localization and dosimetry in the simulation room. Manual
afterloading technique refers to the loading of the radioactive sources
manually compared to remote afterloading that will be discussed in the next
chapter. Afterloading technique is used for temporary implants only.
EXERCISE 14.1 Identify two exposures that has not been eliminated with afterloading?
A wide variety of applicators, afterloading catheters, and templates are

available to assist the implantation of radioactive sources into almost any
anatomical part of the body. The applicators and afterloading catheters are
closed end devices and serve two purposes: (a) as a means of creating
pathways so that radioactive sources can be properly positioned for treatment
and (b) to prevent the radioactive sources in contact with the patient to avoid
contamination. Figure 14.1 depicts a single leader catheter with a half-moon
Therapeutic Radiological Physics 445
button and a flexi-needle used in interstitial implants.1 The catheters are

actually plastic tubes with 16 gauge (G) size in the form of a single or double
leader tubes. The plastic catheter is drawn
behind the stainless steel needles inserted
into tissue at the time of surgery. The
catheters are secured to the tissues using
plastic as well as crimped metallic buttons.
Longer catheters with guide wire of length
of 100 or 150 cm called bronchial tubes
are used for endo-bronchial implant. The Figure 14.1 Afterloading catheter and
guide wire is used to provide rigidity to Flexi needle
the catheter when in the patient. Figure
14.2 depicts the Fletcher-Suit-Delclos applicator set which is a specialized
applicator set designed for gynecological treatments.
Specialized templates have been
designed for use in the treatment of the
cervix and rectum as shown in Figure
14.3. These templates are made of plastic
block with holes drilled in circular pattern
to accommodate needles. Such templates
have a central plastic rod for insertion into
the body cavity and oblique needle
direction to avoid bony structures. The Figure 14.2 FSD applicator set
rod may have grooves to accommodate additional needles. In principle the
use of template would produce uniform line of sources and hence uniform
dose distribution pattern.
Sometimes, radioactive sources are left permanently inside the patient.
This type of implant is called permanent
implant otherwise it is called temporary
implant. For permanent implants, the
radioactive seeds are inserted, injected
directly into, or placed over the surgical
bed or tumors and left to decay. Usually
the seeds come in loose form (individually
Figure 14.3 Template to guide needle
separated seed) or in sutured form (attached insertion
like on a string with 1.0 cm separation).
Isotopes with short half-life and low photon energies are desirable in
delivering the dosage in a relatively short time and simplify radiation
protection concerns. On the other hand, isotopes with long half-life and high
photon energies are often used for temporary implants. Here, the radioactive
sources are loaded into catheters or applicators placed in the lesion and are
immediately removed after treatment. During the treatment, the patient has to
be isolated in a private room to limit exposure to the public.
If the sources are placed on the surface of a lesion outside the patient,
the treatment procedure is called mold or superficial brachytherapy. The
1
http://www.teambest.com/products.html
term plesiotherapy is sometimes used for close proximity placement of

sources to the tumor. Typically these sources are inserted into a mold and
then held against the lesion. If the radioactive sources are inserted directly
into the tumors, the procedure is called interstitial implant or interstitial
brachytherapy. When radioactive sources are placed inside a body cavity,
the treatment procedure is called intracavitary brachytherapy (also called
endocavitary brachytherapy). Intracavitary brachytherapy is most commonly
employed in the treatment of gynecologic malignancies. There is yet another
kind of treatment procedure called luminal brachytherapy where a ribbon of
radioactive sources is inserted into tube-like anatomy such as the bronchus or
esophagus. In recent years, intra-vascular brachytherapy has been used in
the treatment of restenosis of the coronary arteries. Here, radioactive sources
such as strontium-90, phosphorous-32 or iridium-192 are inserted into the
coronary artery to deliver the radiation dosage to prevent occlusion.
14.2 Source Strength Specification
Over the years, the strength of brachytherapy sources has been

specified in a number of ways.2 In the early days, implants were performed
using exclusively radium-226 and its daughter byproduct radon-222. Hence
the strength of radium substitutes (isotopes that replaced radium) was
specified using the milligram radium equivalent or equivalent mass of radium.
This allows the continued use of established dosage tables in particular for
intracavitary and interstitial implants. With the introduction of newer
treatment techniques and dosimetry systems, the strength of the sources was
specified in terms of activity. This specification is appropriate for bare source.
However, brachytherapy sources are usually encapsulated to prevent
contamination. Some of the radiation especially alpha rays, beta rays and low
energy photons are absorbed in the encapsulation and therefore do not
contribute to the radiation treatment. This concern leads to the specification of
the source in terms of apparent activity. Finally, the current method of source
specification is the air kerma strength. These terms will be discussed below.
The idea of radium equivalent was based on the concept of same
exposure rate from a radionuclide at a particular distance compared to radium
source. Mathematically, the source strength (Raeq) can be written as
*
Raeq A( ) (14.1)
*Ra
where A is the activity of the source, * is the exposure rate constant of the
radionuclide, *Ra is the exposure rate constant of radium-226 and Raeq is the
2
AAPM Report No. 21. Specification of brachytherapy source strength. New York, NY: American
Institute of Physics, Inc.; 1987.
strength of the source expressed in milligram radium equivalent. From

equation (14.1), the conversion to milligram radium equivalent (mg Raeq) is
basically the ratio of the exposure rate constants of the respective
radionuclides.
EXAMPLE 14.1 A patient was implanted with 60 mg Raeq of cesium-137. Express this amount
of radioactivity in terms of mCi.
SOLUTION:
§ R cm ·
2
(60 mg )¨¨ 8.25 ¸¸
Ra eq *Ra © mg h ¹
A 151.8 mCi
*cs § R cm ·
2
¨¨ 3.26 ¸¸
© mCi h ¹
The exposure rate constant refers to the exposure rate at a reference

point (or specified distance). For convenience, this reference point is typically
taken to be at 1 m along a line that is perpendicular and bisects the source.
The exposure rate is a measured quantity and hence it is traceable to the
standard at National Institute of Standards and Technology (NIST). The
exposure rate per unit activity at the Table 14.1 Exposure rate constants for a few
reference point from only gamma rays nuclides
of a radionuclide is referred to as the (*G)x
Radionuclide Source Model Rcm 2
/mCih
specific gamma ray constant (*).3 This
term is later replaced by the exposure radium-226 --- 8.25 a
rate constant denoted as *G to include radon-222 --- 10.15
cesium-137 Tube (3M) 3.28
both x-rays and gamma rays with cobalt-60 --- 13.07
energies greater than G as defined in gold-198 --- 2.35
the ICRU Report 19.4 The exposure iridium-192 Best Medical 4.60
iridium-192 Alpha-Omega 4.80
rate constants for a few brachytherapy iridium-192 HDR 4.60
radionuclides are listed in Table 14.1. iodine-125 All Types 1.45
Another term called specific x-ray palladium-103 All Types 1.47
constant (*x) takes into account only x- aExpressed in mg

rays with energies greater than a lower
limit (G). Essentially the exposure rate constant is the sum of the specific
gamma ray constant and the specific x-ray constant as
*G * *x (14.2)
The radiation exposure can be calculated based on the knowledge of

photon fluence and the energy absorption coefficients in air for different
photon energies as explained in Section 5.5. The exposure rate constant
3
ICRU Report No. 10(e). Radiobiology Dosimetry. International Commission on Radiation Units
and Measurement. Washington (DC): US Government Printing Office, 1963.
4
ICRU Report No. 19. Radiation Quantities and Units. International Commission on Radiation
Units and Measurement. Washington (DC): International Commission on Radiation Units and
Measurements, 1971.
provides a means of converting activity into exposure rate. The dose rate is
derived by multiplying the exposure rate with the f med factor, converting
roentgen into cGy in tissue.
As described in Chapter 1, the activity of a source is usually expressed in
Becquerel (Bq), which is one disintegration per second (dps). The older unit
of activity is the Curie (Ci). One Ci represents 3.7 x 10 10 dps, which is the
disintegration of 1 gram of radium-226. With better instrumentation, the
activity of 1 gram of radium-226 was found to be 3.61 x 1010 dps. However
the definition of Ci remains unchanged, i.e. 1 Ci = 3.7 x 1010 dps.
With the encapsulation, some of the emitted radiations are absorbed
and hence do not contribute to the treatment. The exposure rate as measured
from the encapsulated sources is therefore different from a bare source. To
account for this difference, the term content activity and apparent activity
were introduced. Content activity refers to the actual activity of the source.
On the other hand, apparent activity refers to the activity of a source that
yields the same exposure rate of a bare source. In general, the content activity
should be larger than the apparent activity because the encapsulation absorbs
part of the radiation. The difference is larger for low energy photon emitters
compared to high-energy photon emitters.
Although exposure rate at a reference point has been used extensively,
it is currently being phased out in lieu of a new quantity called air kerma rate
at a reference point. The formalism for measuring the reference air kerma
rate is the same as reference exposure rate, e.g.,
* AKR
K air A( ) (14.3)
d2
where A is the activity, *AKR is the air kerma rate constant, and d (1 m) is the
distance from the source at which the air kerma rate is measured. The air
kerma rate constant is related to the exposure rate constant as
0.876 x 102 Gy / R PGy/R

* AKR *G ( 10
)=236.8 *G (14.4)
3.7 x 10 Bq / Ci GBq/Ci
where *AKR has the unit of PGym2GBq-1h-1 with *G in unit of Rm2Ci-1h-1.

The relationship between the two constants for a few nuclides is given in
Table 14.2. Noticing equations 14.3 and 14.4, the air kerma rate is the dose
rate in air at a specified distance and is Table 14.2 Air kerma rate constants
obtained by multiplying the exposure (*G)x *AKR
rate with the mean energy expended per Radionuclide Rm2/Cih PGym2/GBqh
ion pair (W/e),
cesium-137 0.328 77.6
cobalt-60 1.307 309.4
W
K X ( )
gold-198 0.235 55.6
(14.5) iridium-192 0.460 108.9
e
The value for (W/e) in dry air is 0.876 x 10-2 Gy/R, which is a conversion from
R to Gy.
EXERCISE 14.2 Perform the conversion from 0.876 cGy/R to 33.97 J/c for (W/e), the energy
expended in dry air.
EXAMPLE 14.2 Determine the conversion factor from mCi to U for cesium-137 if the
exposure rate constant (Table 14.1) is 3.28 Rcm2/mCih.
SOLUTION:
2
R cm cGy
K A ( *G ) x (0876) (3.28 )( 0.876 )
mCi h R
2
cGy cm U
2.873 2.873
h mCi mCi
The air kerma strength is defined as the product of the air kerma rate in “free
space” and the square of the distance (d) of the calibration point from the
source measured along the perpendicular bisector of the source, e.g.,
SK K. d2 (14.6)
The air kerma strength and the air kerma rate will have the same numerical
value but includes the distance squared in the units. The unit for air kerma
strength is PGym2h-1 which is assigned U for convenience though it is not an
SI unit. The mathematical representation for the unit U is
PGy m2 cGy cm2

1U 1 1 (14.7)
h h
EXAMPLE 14.3 Compute the air kerma strength of 5 mCi of iodine-125. The exposure rate
constant of iodine-125 given in Table 14.1 is 1.45 R Table 14.3 Source strength conversion
cm2/mCih. factors
SOLUTION: (*G)x SkoAapp
SK K d
2 ª cGyy º 2
) d
Radionuclide Rcm2/mCih U/mCi
«¬X(0
X(0.876
876
R »¼
ª º radium-226 8.25 a 7.227
§ R cm2 · radon-222 10.15 8.891
« 5 mCi ¨ 1.45 ¸ »
« ¨ mCih ¸¹ § cGy · » 2 cesium-137 3.28 2.873
©
« x ¨ 0.876 ¸» d cobalt-60 13.07 11.449
« 1m2 x § 1 x10 cm · © R ¹»
4 2
« ¨
¨ ¸
¸ » gold-198 2.35 2.059
¬ © 1m2 ¹ ¼ iridium-192 4.60 4.030
iridium-192 4.80 4.205
§ 4 cGy · § 1x10 PGy ·
4
2
¨ 6.35x10 ¸ ¨ 1cGy ¸ 1m iridium-192 4.60 4.034
© h ¹© ¹ iodine-125 1.45 1.270
palladium-103 1.476 1.293
PGy m2
6.35 6.35 U
h a
Expressed in mg
The relationships or conversion factors between source strengths in U and

mCi for a number of radionuclides are given in Table 14.3.
14.3 Brachytherapy Source Characteristics
Table 14.4 presents a number of sealed sources that have been used or
under investigation in brachytherapy. Radium-226 (226Ra) which is the sixth
member of the naturally occurring radioactive uranium-238 series and its
daughter byproduct radon-222 Table 14.4 Brachytherapy sources
(222Rn) have a long history of Energy Half-life HVL
clinical use. Their uses had Radionuclide (MeV) (d,y) (mm Pb)
discontinued because of safety
radium-226 0.2 - 2.2 1622 y 14
concerns of chemical and radon-222 0.78 3.83 d 14
radiation toxicities. Its daughter americium-241 0.060 432.9 y 0.12
byproduct radon-222 is a cesium-131 0.030 9.7 d 0.02
cesium-137 0.662 30 y 6.5
hazardous gas and with high cobalt-60 1.25 5.26 y 11.0
energy photon spectrum makes gold-198 0.416 2.7 d 3.3
shielding more difficult. Iodine-125 0.028 (x) 59.6 d 0.02
iridium-192 0.380 74.2 d 3.0
However, they still have a strong palladium-103 0.021 17 d 0.02
influence on modern ruthenium-106 0.097 373 d 0.16
brachytherapy concepts. samarium-145 0.041 340 d 0.06
selenium-75 0.165 120 d 0.03
Ruthenium-106 has been used in strontium-90 0.546 (E) 28.9 y 0.66
Europe for eye plaque therapy but tantalum-182 1.1 144.4 d 10
not in the United States. Cobalt- ytterbium-169 0.93 32 d 0.48
californium-252 2.35 (ave) 2.65 y
60 are also used in eye plaque neutrons
therapy. Iridium-192 has replaced
tantalum-182 as interstitial source
because of the energy spectrum (0.043 to 1.453 MeV). Because of its short
half-life, gold-198 has been used for permanent implants but has been
replaced with iodine-125. Californium-252 is a neutron source used as
temporary implants to treat radio-resistant tumors that are bulky and oxygen-
deficient.5 The radiobiological effectiveness (RBE) is in the range of 6.5 – 7.0
and found to be particularly successful in the treatment of cervical cancers.
Selenium-75, samarium-145, ytterbium-169, and americium-241 have been
investigated as potential new brachytherapy sources. It should be mentioned
that phosphorus-32, iodine-131, and strontium-89 are being used as unsealed
sources for radiopharmaceutical therapy which will be discussed in Chapter
17.
Brachytherapy sources are constructed (a) to provide source rigidity,
(b) to contain the radioactivity, (c) to absorb alpha-particles and beta-
particles, and (d) to be visible radiographically. Hence radiation fluences that
contribute to the treatment are gamma-rays and characteristics x-rays. The
5
Maruyama, Y.; Wierzbicki, J.G.; Vtyurin, B.M. et al. Californium-252 Neutron Brachytherapy.
In: Nag, S. editor. Principles and Practice of Brachytherapy. Armonk: Futura Publishing; 1997:
649 – 687.
choice of radioisotopes for brachytherapy depends on a number of factors

including (a) photon energy, (b) half-life, (c) half-value layer (HVL) in shielding
materials, (d) specific activity, (e) source strength, (f) decay scheme and (g)
inverse-square dose fall-off. The photon energy has impact on the tissue
penetration and radiation protection requirements. Lower photon energies
allow for simpler radiation protection with less shielding and radiation safety
restrictions. The half-life of an isotope is a critical factor to be considered for
both temporary and permanent implants. It describes the strength of the
source and may decide the treatment time of the implant. Shorter half-life
nuclides are generally used in permanent implants to allow for faster rate of
dose delivery. For temporary implants, source placement is more frequent for
short half-life nuclides.
EXAMPLE 14.4 Compute the percent activity decay of cesium-137 for every six months or half
a year.
SOLUTION:
A .693
exp( x 0.5 yr ) exp( 0.01155) 0.989
A 30yr
o
The percent activity decay is 1-0.989=0.011 or 1.1%
The specific activity influences the ease and ability to fabricate the source with
reasonable size for nominal source strengths. Simpler decay scheme of the
radioisotope allow for more accurate dose calculations. Brachytherapy
sources are generally small to allow for easy insertion into the afterloading
device. They are available in various mechanical forms such as needles,
tubes, seeds, ribbons, wires, and pellets. Regardless of the constructions,
brachytherapy sources are sealed sources. Usually, they are doubly-
encapsulated in platinum (Pt) or stainless steel to prevent radioactive leakage
and to filter out alpha-particles, beta-particles, and low energy photons to
reduce the likelihood of radiation necrosis adjacent to the sources. As a result
of the filtration, only high-energy photon or neutron component delivers the
therapeutic dose.
The seven sources that are currently in use are (a) cobalt-60, (b)
cesium-137, (c) iridium-192, (d)
iodine-125, (e) palladium-103, (f)
cesium-131, and strontium-
90/yttrium-90. Cesium-131, iodine-
125, and palladium-103 (103Pd) seeds
are currently used in prostate
permanent implants. Because of its
Figure 14.4 Design of iodine Model 6702 seed
popularity, several manufacturers [From AAPM Report No. 84]
have been involved in the
production of iodine-125 seeds leading to different physical designs of the
seeds. The physical characteristics of these seeds are given in the AAPM Report
No. 84.6 As a sample, the seed model 6702 is depicted in Figure 14.4. The
seed is about 45 – 50 mm in length and about 0.8 mm in diameter. Because of
the welded ends of the encapsulation, the dose distribution is distorted (see
Figure 14.5) and hence requiring physical measurements as described in the
report. Of these three isotopes, the longest half-life with the highest photon
energies is iodine-125. Most of the dose is delivered over 6 half-lives, which is
approximately one year for iodine-125. Permanent implants of 125I delivers
100 – 200 Gy for total decay with initial dose rates on the order of 5 – 10
cGy/hr. Because of the low energy photons with HVL of 2.0 cm in tissue for
iodine-125, the radiation protection precaution is simple.
Iridium-192, cobalt-60, and cesium-137 sources are used in remote
afterloading systems. Their half-lives are given in Table 14.4 and their decay
scheme of some of these radionuclides can be found in chapters 8 and 9 of the
first textbook.7 Iridium-192 sources had been fabricated in the form of wires
or seeds for interstitial implants. The seeds
about 3 mm long and 0.3 mm diameter are
spaced 1 cm apart and press-fitted in nylon
ribbons. Cesium-137 sources which
replace radium-226 in gynecological
temporary implants had been fabricated in
the form of tubes. The source length is
about 20 mm long with a 14 mm active
length and 3 mm diameter.
Figure 14.5 Isointensity around an

14.4 Cumulative Doses iodine-125 seed
The concept of cumulative dose is basically the same as the cumulative

(cumulated) activity as explained in section 8.4.8 The rate at which an implant
delivers the cumulative dose to the tumor depends on the half-life of the
radionuclide, time duration of implant, and the source strength. The
cumulative dose is the sum of the dose rate over time and can be written
mathematically as
t2
~
D ³ D (t ) dt
t1
(14.8)
where D (t ) represents the dose rate at time t. The integration of dose starts
from time t1 to t2 where t2 > t1. For long half-life, the cumulative dose is the
6
AAPM Report No. 84. Update of AAPM Task Group No. 43 Report: A revised AAPM protocol
for brachytherapy dose calculations. College Park, MD: American Association of Physicists in
Medicine; 2004.
7
Saw, C.B. Foundation of Radiological Physics. Omaha, NE: C.B.Saw Publishing, 2004.
8
Saw, C.B. Foundation of Radiological Physics. Omaha, NE: C.B.Saw Publishing, 2004. Chapter
8 – Radioactivity.
product of initial dose rate and the treatment time. On the other hand, for
short half-life radionuclide, the cumulative dose is also dependent on the
radionuclide or source strength decay.
EXERCISE 14.3 Show that the cumulative dose for a temporary implant with short half-life is
D 1.443WDo [1 e
0.693
0 693 t / W is the initial dose rate, W is the half-life, and t is the
] , where D 0
time duration.
For complete decay, the cumulated dose is derived to be the product of the
average half-life and the initial dose rate as
~
D W ave D 0 1.443 W D 0 (14.9)
The concept of complete decay is important in permanent implants where the

radioactive sources are left in the tumor to decay. Shorter half-life
radionuclides are used to treatment more malignant tumor to provide faster
dose delivery with cell killing in the first few half-life of the procedure. If the
implant is used without the combination of external beam radiation therapy,
the treatment is called monotherapy.
EXAMPLE 14.5 Compute the initial dose rate for a cesium-131 permanent implant to deliver
115 Gy in the monotherapy of the prostate.
SOLUTION:
D 115 Gy
D0 0.34 Gy / h
1.443
1 44 W 1443 x 9.7d x (24 h / d)
14.5 Calibration of Brachytherapy Sources
According to NRC (part §35.432) regulatory guidelines, the output or activity

of a brachytherapy source must be determined using a calibrated dosimetry
system that is directly traceable to the National Institute of Standards and
Technology (NIST) prior to its first medical use. By directly traceable to NIST,
a source is implied to have a direct comparison to the same type of source
calibrated by NIST. The system must be calibrated within two years or after
performing servicing. Instead of measuring the brachytherapy source at the
local facility, the regulation also allows the use of measurements provided by
the source manufacturer made in accordance to the above requirements. If
the measurements made by the source manufacturer are used, they must be
corrected for physical decay. As a general, it is a good practice to validate
that the source output is corrected.
There are two general techniques of measuring the output of a
brachytherapy source in a clinical setting. The first technique is the
measurement of exposure rate at a large distance from the source. This
arrangement approximates the point source geometry. The arrangement

requires (a) a large laboratory workspace, (b) a large sensitive ion chamber,
and (c) a method of creating a “good” geometry.
All these requirements make the implementation
of this method impractical in a clinical setting.
The next technique is the use of well-type ion
chamber (also called re-entrant chamber) as shown
in Figure 14.6.9 This well-type chamber model
HDR1000 Plus is used for both low dose rate and
high dose rate brachytherapy. The use of this
device for calibration is much simpler and is the
technique of choice. The well-type ion chamber
is very sensitive since the wall of the ion chamber
is constructed to surround the source giving almost
Figure 14.6 Well-type chamber
the 4S geometry of detection. This property is for brachytherapy
important since the activity of brachytherapy
sources is typically low. The chamber can be of the open-air type or filled
with argon gas. If the chamber uses source
argon gas (99.995% purity) pressurized screw holder
to 14.7 psi, the chamber does not need

correct for the effect of air temperature pressurized
gas wall
and pressure. The wall and electrode electrode
of the ion chamber is typically made of

aluminum. The collection potential source
applied can be 150 or 300 volts collection

electrode
depending on the model. The guard
electrode
schematic design of a well-type ion
chamber is shown in Figure 14.7. Figure 14.7 Schematic design of a well-type
ion chamber
Well-type chambers generally
exhibit strong energy dependence arising from the absorption and scattering of
photons and electrons in the chamber
walls and the gas. In addition, there is
also intrinsic energy dependent on the
source such as oblique filtration through
the source encapsulation and energy
spectrum. The well-type chamber gives
an enhance response at low photon
energies (which is the characteristics of
brachytherapy source) through
Figure 14.8 Source position verification
photoelectric absorption. As such, the
chamber should be calibrated for the isotope for which the activity is to be
measured. In addition, the well-type chamber also exhibits central axis
positional dependency. Usually source holders as shown in Figure 14.8
specially designed for various seed configurations are used to accurately
9
http://www.standardimaging.com.
reposition the sources at specific location along the central axis where the
positional dependency is the least. This is usually at the center of the
chamber where the detector response is maximized and the region of uniform
is the largest. This region of uniform detection response for the Standard
Imaging model HDR1000 Plus well chamber will be examined in the next
chapter. If this is not possible to place the sources at the optimal position,
correction factor to source position and length of source may be used.
EXAMPLE 14.6 A re-entrant well chamber model HDR1000 plus was sent to the ADCL
laboratory for calibration. An air-kerma strength calibration coefficient was reported as 2.053
x 1011 PGym2h-1A-1 for iodine-125 SourceTech Model STM125I source. What is the reading
of the re-entrant chamber in pA for 1 mCi source?
SOLUTION:
The unit conversion from mCi to U and vice-versa is taken from Table 14.3
PGy m 2 11 PGy m
2
I 1.270 / 2.053x10
h mCi hA
12
6.186x10 A 6.186 pA
Well-type chambers will respond to scatter radiation. When used, they

should be placed well away (at least 25 cm) from walls that may scatter
radiation back to the chamber. In the best situation, the chamber should be
used in the same location, in a constant geometry and in a reproducible
manner. If the chamber has to be moved, adequate time should be allowed
for the well chamber to reach temperature equilibrium with the room.
14.6 Dose Calculations of a

Linear Source
A brachytherapy source is
encapsulated to increase integrity
and as well as to avoid
contamination. The encapsulation
also filters out alpha rays, beta rays,
and also low energy photons. The Figure 14.9 Geometric relationship for dose
calculation from a linear source
exposure rate is therefore reduced.
This section examines how the dose can be computed from a linear source.
The exposure rate around a linear source can be calculated using Sievert
integral. It consists of dividing the line source into segments sufficiently small to
apply inverse square law and filtration. Consider a source of active length L and
filtration t as shown in Figure 14.9. The exposure dX at a point P from a small
active source element with length dx is given as
A 1
dX * dx 2 ePtsec T (14.10)
L r
where A and * are the activity and exposure rate constant of unfiltered source
and P is the effective attenuation coefficient of the filter. Using the following
geometric relationship,
r h sec T
x h tan T (14.11)
dx h sec 2 T dT
equation (14.10) can be integrated to obtain the exposure rate from the whole
source as
A* T2 Ptsec T
Lh ³T1
X(p) e dT (14.12)
EXERCISE 14.4 Perform the integration of equation (14.10) to obtain equation (14.12).
A few corrections are applied to the exposure rate obtained using Sievert
integral. Although small, a correction factor is needed to account for self-
absorption in the source material. The next correction factor is the varying
thickness that is used to encapsulate the source. Also the filter alters the
energy spectrum and hence an effective attenuation coefficient that varies with
thickness is required. This issue is more severe when considering the effect of
oblique filtration through the source.
14.7 Point Source Approximation
In the past, the dose distribution for interstitial seed implant was
computed using the point source approximation instead of linear source. The
point source approximation was necessary because computer calculations were
slow and disk storage space was limited. To understand the effect of this
approximation, we reduce equation (14.12) by ignoring the filtration through the
encapsulation. Under such assumption, the exposure rate at a point P located in
a plane that bisects the source at a distance h would be given as
2A* §L ·
X(p) tan1¨ ¸ (14.13)
Lh © 2h ¹
Equation (14.13) provides a method of computing the exposure rate of a linear

source of any length. Typical seed length is about 5 mm.
EXERCISE 14.5 If the point P lies in the central plane and neglecting filtration, shown that
equation (14.12) reduces to equation (14.13).
Figure 14.10 shows a comparison 5 Point Source
Relative Exposure Rate

Line Source (2 cm)
between a point source and a 2- 4
cm linear source as a function 3

distance. At large distance, the
2
exposure rates from a point source
and a linear source are basically 1
the same. At shorter distance, 0

0 1 2 3 4 5 6
there is difference between the Distance (cm)
two exposure rates. The exposure Figure 14.10 Exposure rate from line and
rate for the point source point source
approximation is higher than the linear source approximation. The difference
between the exposure rates gets larger as the distance to the source gets
smaller. As a general rule we take a line as a point source so long as the point
of interest is at least twice the length of the source. Using this rule, the
difference in exposure rate is about 2%. The exposure rate is therefore the
same at a distance of 1.0 cm for a typical seed source of 5 mm.
EXERCISE 14.6 Derive the two expressions used to plot Figure 14.10.
EXAMPLE 14.7 Compute the exposure rate at 3 cm away from a 6 cm long iridium-192
source having 15 mCi using a) a point source approximation and b) a line source formalism.
SOLUTION:
a) Exposure based on point source approximation is
A*
X= 2
r
(15 mCi)(4.60 R-cm2 /mCi-h) 69
R / h 7.67 R / h
(3 cm)2 9
b) Exposure based on line source formalism is
2A* 1 §L · 2(15mCi)(4.6 R cm / mCi h) 1 § 6cm ·
X tan ¨ ¸ tan ¨ ¸
Lh © 2h ¹ (6cm)(3cm) © 2(3cm) ¹
138 R / h 1
tan (1) 6.02R / h
18
The exposure from a line source is always less than a point source. This is
due to the increase inverse square effect from the segment source away from
the perpendicular bisector source.
14.8 Traditional Dose Calculation Formalism

The traditional dose calculation formalism used in brachytherapy for

many years was based on in-air dosimetric quantities. The traditional dose
calculation formalism had been used to compute the dose distribution of
iridium-192, iodine-125, and palladium-103. Using the point source
approximation, the dose rate at a distance r from a source is given as,
( r) A app (*G ) x g med T(r) Ian

D (14.14)
r2
where A app is the apparent activity of the source, (*G ) x is the exposure rate
constant for the radionuclide, g med is the exposure-to-dose conversion factor,
T (r) is the tissue attenuation factor, and Ian is the anisotropy constant. Since
the source strength is expressed in apparent activity of a radionuclide, it takes
into account the attenuation of photons through the source encapsulation.
The apparent activity, which is defined as the activity of a bare source that
produces the same exposure rate at a reference point, is used in particular for
iodine-125 and palladium-103 seeds. For iridium-192, the common unit used
is the milligram radium equivalent, which can be converted to milliCurie
(mCi) using the ratio of their exposure rate constants. Equation (14.14)
requires the source strength to be specified in apparent activity because the
attenuation term is not explicitly shown into the equation. The term, (*G ) x
called the exposure rate constant relates the source strength to the exposure
rate at a reference distance, typically taken to be one meter. The subscript G
denotes that all photons with energies less that G do not contribute to the
exposure rate constant. The g med converts exposure in air into dose in a
medium. This value varies with the energy of emitted photons. The
commonly used exposure to dose conversion
Table 14.5 g med values for a
factors is listed by Table 14.5. The tissue
few radionuclides.
attenuation factor T (r) accounts for the tissue
Radionuclide g med value
absorption and scattering as a function of
distance from the source. The absorption and cesium-137 0.962
scattering function depends on the medium iridium-192 0.962
surrounding the sources as well as the gold-198 0.962
iodine-125 0.92
characteristics of the radiation emitted from the palladium-103 0.92
sources. In general, the scattering in tissue effect
compensates the photon absorption in tissue
effect for photon energies above 100 keV. The tissue attenuation have been
experimentally measured for a number of radionuclides by Meisberger et al.
as a ratio of exposure in water to exposure in air at a particular distance as
Exposure in water (r )
T(r ) (14.15)
Expsoure in air (r )
1.1
It is fitted to a polynomial of the 1.0
Tissue Attenuation Function

iridium-192
form 0.9 cesium-137
radium-226
0.8
T(r) = C 0 C1r C 2r C 3r
2 3
(14.16) 0.7 gold-198
0.6
The tissue attenuation factors for a
0.5
number of radionuclides are shown 0 5 10 15 20
Distance from source (cm)
in Figure 14.11. The anisotropy
constant Ian accounts for the non- Figure 14.11 Tissue attenuation factor as a
function of distance from a source
isotropic emission of photons from
an encapsulated source. This anisotropy is due to nature of the source design
and differential oblique attenuation by the encapsulation. This anisotropy
constant is obtained by averaging the exposure rate around the source at a
fixed distance in air. The anisotropy constant is assumed to be independent of
the distance from the source center.
Lastly, equation (14.16) varies inversely to the square of the distance
from the source, which is referred to as the inverse square law. This inverse
square law is very important in brachytherapy since doubling the distance
would reduce the exposure rate by 75%. The next impact is on the fact that the
radioactive sources are seeds and not point sources.
P(r,T)
14.9 Dosimetry Based on TG-
43 Formalism
P(ro,TR)
In 1995, the AAPM Task T
Group No. 43 recommended a new
dosimetry protocol for dose
calculation of interstitial Seed Source
brachytherapy sources.10 The Figure 14.12 Coordinat e system used in
formalism in modular form permits TG43 protocol
the computation of doses in two
dimensions for iodine-125, palladium-103, and irdium-192 sources. Along
with the recommendation for new dose calculation formalism, new and
updated physical quantities such as the air kerma strength, radial dose
function, anisotropy function, anisotropy factor and dose rate constants were
introduced. These quantities have been derived directly from measured dose
rates in a water medium around the sources and Monte Carlo simulations. In
contrast the traditional formalism uses exposure rate constant, tissue
10
AAPM Task Group Report No. 43 Dosimetry of interstitial brachytherapy sources:
recommendations of the AAPM Radiation Therapy Committee Task Group No. 43. Med Phys. 22:
209-234; 1995.
attenuation factor, exposure-to-dose conversion factor and anisotropy factor.

All of these old quantities are not needed in the TG-43 dose calculation
formalism.
The polar coordinates (r,T) system as shown in Figure 14.12 is used in
the dose calculation formalism. According to TG-43, the dose rate D (r, T) at a
point P(r, T) as shown in the figure is given by
(r, T) G(r, T)
D Sk / g(r) F(r, T) (14.17)
G(ro , To )
where S k is the air kerma strength of the source, / is the dose rate constant,
G(r, T) is the geometry factor, g( r ) is the radial dose function, and F(r, T) is the
anisotropy function. The reference point (ro , To ) is chosen to lie on the
transverse bisector of the source at a distance 1 cm from its center, i.e., the
point at (1,S/2) as illustrated in the figure. In a point source approximation,
the anisotropy function is reduced to an anisotropy factor I an (r) . It is obtained
by integrating the anisotropy function over the angular coordinate around the
source. The dose rate constant / is defined as the dose rate in water at a
distance of 1 cm on the transverse axis for 1 U source. It is an absolute
quantity unlike other terms in the equation and vary with the source geometry
that include the effects of spatial distribution of radioactivity within the source,
encapsulation, self-filtration with the source and scattering in water
surrounding the source. As such, there is no unique dose rate constant for a
particular radionuclide. For example, the exposure rate constant of iridium-
192 is equal to 4.69 R cm2 mCi1 h1 and it is independent of its length,
diameter, or encapsulation of the actual source; it is a physical constant for the
radionuclide iridium-192. But, the dose rate constant will be different for
different length of iridium-192 wire, etc. The geometry factor, G(r, T) accounts
for the variation of relative dose due to the spatial distribution of activity
within the source only, ignoring photon absorption and scattering in the
source structure. For a point source, it is the inverse square law and for line
source approximation identical to those used in the traditional dose
calculation formalism. Specifically, for a point source, it is given by
G(r, T) ro2
(14.18)
G(ro , To ) r2
which is an inverse square factor since ro = 1 cm. The radial dose

function, g( r ) is the relative dose rate falloff along the transverse axis of the
source in the medium. It accounts for the effects of absorption and scatter in
the medium. The radial dose function is measured along the transverse axis of
the source and it is normalized to unity at the reference distance of r ro 1
cm. The anisotropy function F(r, T) describes the anisotropy of the dose
distribution around the source, including the effects of absorption and

scattering in the medium. It represents a two-dimensional function that maps
the angular variation of dose rate about the source caused by the various
filtering effects such as self-filtration, oblique filtration, and scattering of the
medium. The inverse square effect is suppressed in the anisotropy function
because it is already present in the geometry function. The anisotropy
function is normalized to unity at the reference angle, T To S / 2 at the
same distance.
All dosimetric values into equation (14.17) are provided in the TG-43
report except for the air kerma strength, S k and are given in the appendix in
this text.
The dose rate obtained using the TG-43 dose calculation formalism and
updated source dosimetry data can be expected to be different from the
traditional dose calculation formalism by as much as 17%. For the same
treatment and implementing the TG-43 dosimetry with point source
approximation, the widely prescribed dose of 160 Gy for iodine-125
permanent implants using model 6711 sources changes to 144 Gy. The
conversion to TG-43 dose formalism should not alter the actual treatment dose
that is based on past experience but results in a recorded lower dose. In other
words, the iodine-125 implants delivering 160 Gy were actually delivering
only 144 Gy according to TG-43 formalism. Since the recorded dose is
significantly different due to the new dosimetry data, it is recommended that
the change to the recommended dose calculation formalism be explicitly
stated in patient’s record. It would be prudent to state doses as 144 Gy (TG-
43) which used to be 160 Gy (pre-TG-43). As pointed out above, there are
large differences in the dosimetry of the iodine-125 sources using the TG-43
dose calculation formalism compared to the traditional dose calculation
formalism. No significant changes for other brachytherapy sources are
recommended.
14.10 Methods of Source Localization
In order to perform dose calculations following either the traditional or

TG-43 dose calculation formalisms, the spatial coordinates of individual sources
in three dimensions must be known. The process of determining these
coordinates is called source localization. A number of source localization
methods such as stereo shift, orthogonal, non-orthogonal, isocentric, and three-
film- technique methods have been used and all use radiographic methods. As
such, these sources must be fabricated such that they can be visible on
radiographs. The effectiveness of a treatment depends on the ability to identify
the target relative to the dose distribution, which is usually not possible using
these source localization techniques. Hence, three-dimensional imaging
modalities, which are capable of identifying targets and radioactive sources, are
becoming common. In this section, we shall examine the underlying principles
of stereo shift, orthogonal, three-film methods of source localizations.
The stereo shift technique was commonly used before the introduction
of isocentric simulators. In the stereo shift technique, the film plane is fixed
while the source is moved linearly by a known distance d between the two
films as shown in Figure 14.13. Source S2 d 1 S
The height (h) of each source Travel
above the film plane can be

determined if the height of a
reference point (O) above the film F
P
plane is also known. If O is the O
origin of a coordinate system, the h
f
z- coordinate of the source is A B C D
Film
determined by taking the Location t
Y
difference between the heights 1
2 Y
above the film plane as Figure 14.13 Stereo shift technique
z h f (14.19)
where f is the height of the origin above the film plane. The magnification of
the source is the given as
F
Mag (14.20)
Fh
where F is the x-ray source to film distance. The other two coordinates are
determined by taking a radiograph with central axes passing through the
origin. Both equations (14.19) and (14.20) can be solved if the height of the
source above the film plane (h) can be determined. The similar triangles of
PS1S2 and PAB, and OS1S2 and OCD provide two relationships to solve for h.
The first relationship is
Y1 t d
(14.21)
z Fz
for the similar triangle of PS1S2 and PAB. The second relationship is derived
from the similar triangle of OS1S2 and OCD giving
Y2 t f
(14.22)
f Ff
These two equations can be used to solve for h as
( Y1 Y2 )(F f ) fd
h (14.23)
( Y1 Y2 )(F f ) Fd
Substituting into equation (14.21), the z-coordinate of individual source in an

implant can be determined.
EXERCISE 14.7 Derive equation (14.23).
Orthogonal radiographic technique is the preferred method of source

localization using isocentric simulator. The simulator-based orthogonal
radiographic technique offers the advantages (a) to position film precisely
perpendicular to the x-ray central axes, (b) the accessibility of digital source-to-
patient distance and source-to-film distance values from the simulator for
magnification factor calculation, (c) providing high quality orthogonal
radiographs, and (d) easy accessibility of computer software for this technique
to determine the source coordinates in patient coordinates.
In the orthogonal radiographs technique, two radiographs are taken
orthogonal to each other. Although it is not necessary in terms of gantry
angles, the anterior-posterior (AP)
radiograph and a lateral radiograph as LAT Film
S
shown in Figure 14.14 are commonly

used. Typically, the Cartesian
Z 2
coordinate system is used with the Y- 2
O
axis along the axis of gantry rotation 1
S
Z 1
(simulator unit) or along the direction

of inferior to superior patient direction.
The horizontal axis in the AP AP Film
X 2O 1X
radiograph would be the X-axis. The
Figure 14.14 Radiographs of two seeds in a
patient right-to-left direction represents patient.
the X-coordinate and the patient
superior-to-anterior direction represents the Z-coordinate. As defined, the AP
radiograph would contain the X-Y plane and the lateral film, the Z-Y plane.
The origin of the coordinate system should be chosen to be present in both AP
and lateral films. As defined, the Y-coordinate of each source should be
available on both AP and lateral films. If the two points represents the ends of
a linear source, the length would be determine as
L (X2 X1)2 ( Y2 Y1)2 ( Z2 Z1)2 (14.24)
where notation 1 and 2 represent each end of a linear source.

Most often, the films are prepared for input into the dose planning
computers (also called treatment planning computers) by (a) defining the
origin of the coordinates using the beam axes, (b) the axes of the coordinate
systems, (c) identifying matched location of the sources on both films, and (d)
magnification of the films.
The error associated with the determination of source coordinates using
stereo shift technique is inversely proportional to the distance of x-ray tube
shift. The larger the x-ray tube shifts is, the better is the accuracy in the
determination of the source coordinates. In general a small error in Y
coordinates would produce a large error in the z-value. However, the stereo
shift technique is more suitable than orthogonal techniques in cases with
many sources or masked by overlying bone. Because of the limited shifts, the
stereo shift technique yield less accurate source coordinates compared to the
orthogonal technique. However in orthogonal technique the patient anatomy
landmarks are so different making the source matching difficult.
In selective cases where the implant has too many seeds such as in
prostate implants, orthogonal technique may show fewer sources because of
overlapping as shown in Figure 14.15.
A three-film technique is used to
resolve this concern in which an
additional film is taken between the
two orthogonal films. At this angle the
individual seeds are resolved.
14.11 Isodose Curves

Figure 14.15 Three-film technique to resolve
overlapping sources
The dose distribution of an
implant is the summation of the dose contributions from the individual sources.
The dose distribution of the individual source is described by the TG-43
modular dose calculation formalism using tabular data. The tabular data is
based on the measurement of dose distribution around a single source.
Typically, the doses are computed at points in the form of a grid so that the dose
distribution can be generated in any arbitrary plane. The isodose distribution
can be magnified and superimposed on implant radiograph for viewing the dose
distribution relative to patient anatomy.
The isodose distribution can be
calculated in unit of dose for permanent
implant or dose rate for temporary
implants.
The dosimetric characteristics of
radioactive source does not exhibit a
spherical dose distribution but attenuated
at the source ends due to attenuation by
the encapsulation. Figure 14.16 shows Figure 14.16 Isodose curves of a radium needle
the isodose curve for a single radium.
At close range, the isodose curve is elliptic due to the design of the source and
end filtration. There are also dips at the axis due to oblique filtration. At far
range, the isodose curve becomes circular behaving as if it comes from a point
source. In other words, the isodose pattern can be approximated by a point
source if the region of interest is at distance much farther that the size of the
source. This effect has been discussed in Section 14.7.
14.12 Measurements of Isodose Distributions
Experimental measurement of isodose distributions may be necessary

to confirm the dose calculation algorithm. Film and TLD are used for
brachytherapy dosimetry. Although film offers high spatial resolution, its has a
serious limitation of energy dependence with increased sensitivity to low
energy photons and scattered radiation which are characteristics of
brachytherapy sources. TLD also show energy dependence but to a lesser
degree than film. It is commonly used to measure the dose distribution
around single source. Scintillation detectors have also been used to measure
the relative dose distribution because of its higher sensitivity compared to TLD
and films. Silicon diode detector connected to a scanner has also been used
for relative dose measurement. With its small size, high sensitivity, and
almost complete energy independence, the silicon diode detector seems to be
suitable for brachytherapy dose measurements.
14.13 Implant Dosimetry Systems
The early practice of brachytherapy before 1960 was based on a system

of implant dosimetry. Each dosimetry system had very clear guidelines on the
rules of implantation, dose prescription, and dose delivery time. The rules of
implantation precisely described how the sources should be arranged within
an implant in order to achieve the desired dose distribution so that the dose
prescription and dose delivery time presented in tables are valid. These
systems therefore have elaborate rules for source arrangements and tables of
dosage associated with each type of implants. The most widely used
dosimetry systems were the Paterson-Parker system, the Quimby system, the
Paris system and later the Memorial system. The challenge in the practice of
brachytherapy was to adhere to these rules, which at times can be difficult due
to the unusual tumor shapes and sizes. While the implant dosimetry systems
are no longer practiced, the concept still influences modern brachytherapy.
The two influential implant dosimetry
systems, the Paterson-Parker and
Quimby systems are briefly described Treatment Plane
here. b
Treatment
Depth (h)
In the early 1930s, Paterson and a
Parker in Manchester developed a

system of rules to distribute radium Source Plane b
sources in a tumor to deliver a uniform a
dose through the region to be treated.11

These rules soon became popular Figure 14.17 Definition of treatment plane
throughout the world and set the basis for
11
Meredith W.J. ed. Radium Dosage: The Manchester System. Edinburgh: E&S Livingstone; 1967.
the well-known Paterson-Parker System or the Manchester system of source

and dose distribution used in major cancer centers. In order to achieve this
goal of dose uniformity, the source strength must be distributed non-
uniformly with more concentrated at the periphery of the implant to achieve
a dose variation of within r10% from the specified or stated dose, excluding
the localized high-dose regions around the sources. Thus the specified dose is
nominally 10% higher than the minimum dose in the treatment region.
For planar implants, the dose uniformity is specified in a parallel plane
(treatment plane) at a distance h cm away from the implanted plane (source
plane) within an area bounded by the projection of the implant onto this plane
as shown in Figure 14.17. The implant is constructed by arranging needles in
parallel with a defined separation and two crossed-end needles. The crossed-
end needle is placed at the tips and perpendicular to the parallel needles. As
such, the crossed-ends and the periphery Table 14.6 Source distribution for
needles form a rectangle in which lay parallel planar implants
needles. The rules of distributing the radium Implant Area Fraction @
periphery
for planar implants must be adhered to
achieve the desired results are as follows: (1) <25 cm2 2/3
the ratio of the amount of radium distributed 25-100 cm2 1/2
in the periphery and the amount of radium > 100 cm2 1/3
over the implant area depends on the size of

the implant as stated in the Table 14.6, (2) the spacing of the needles should
not be more that 1.0 cm from each other and from the crossing needle, (3) the
effective area is reduced by 10% for each uncrossed end for the purpose of
determining the dosage from the dosage table, and (4) for multiple implant
planes, the radium should be arranged as in rules (1)-(3), and the planes
should be parallel to each other. Based Table 14.7 Patterson-Parker Planar
on these implantation rules, the amount Implant Tables (mg-hr/1000R)
Area Treatment Distance (cm)
of milligram-hours needed to deliver (cm2) 0.5 1.0 1.5 2.0
1000 R to the treatment region is given
by the Patterson-Parker Dosage Table. A 10 235 433 655 923
portion of the dosage table is given in 20 368 641 910 1225
30 490 795 1142 1487
Table 14.7. If the implant is more 40 603 934 1346 1732
rectangular than square, the milligram- 50 705 1072 1522 1958
hours has to be increased proportionally 60 800 1206 1682 2180
80 981 1473 1966 2562
with the ratio of the side of the rectangle. 100 1155 1716 2238 2890
Elongation 2:1 3:1 4:1
EXAMPLE 14.8 A square mold was designed to Increase 5% 9% 12%
deliver 3000 R to an area 1.0 cm from the
implant. If the implant with an area of 30 cm2
was constructed following the Patterson-Parker system, calculate the number of milligram-
hours to deliver such dosage.
SOLUTION:
a) From Table 14.5, the number of mg-hrs needed to deliver 1000 R is 795 mghrs.
b) The treatment time would be
A 3 x 795 2385 mg hrs
For interstitial applications, the treatment distance is arbitrarily chosen

to be 0.5 cm. As such it represents a treatment of a slab of tissue of 1.0 cm
thick. Two planes are used for the treatment of a slab of tissue up to 2.5 cm
thick. The region to be treated is sandwiched between the two planes. The
average implant area is used to determine the dosage based on 0.5 cm
treatment distance. The number of milligram-hours required to deliver 1000 R
is increased by 1.25, 1.41, and 1.52 for plane separation of 1.5 cm, 2.0 cm,
and 2.5 cm respectively.
EXAMPLE 14.9 A single plane implant was designed to treat a 1 cm thick target volume with
area of 6 cm x 4 cm without one crossed end. If the implant is intended to deliver 3000 R,
what is the implantation time? The implant is designed according to the Manchester rules
using 5 needles 6 cm longs and one needle 4 cm long
using 21 mg of radium. Table 14.8 Patterson-Parker volume
implant tables (mg-hr/1000R)
SOLUTION:
Volume (cm3) mg-hrs
a) Implanted Area A,
2
A 0.9 x 6.0 cm x 4.0 cm 21.6 cm 10 158
b) From Table 14.5, the mg-hrs per 1000 R is 20 251
387.5 mg-hrs for the above treatment area at 0.5 40 399
cm treatment distance. 60 523
c) Dose rate is 80 633
100 735
21 mg
D 1000 R x 54.2 R / hr 140 920
387.5 mg hr 180 1087
220 1243
d) Treatment time t,
Elongation 1.5 2.0 2.5
3000 R Increase 3% 6% 10%
t 55.4 hrs
54.2 R / hr
When the region to be treated is more than 2.5 cm thick, the two-plane
implant is not satisfactory because of the low dosage region located midway
between the planes. In such a case, volume implant in the form of a sphere,
cube, or cylinder and dosage table (Table
Table 14.9 Source distribution for
14.8) can be used. The rules of distribution of volume implants
the radium that must be adhered to achieve Implant Parts
the desired results are as follows: (1) the total volume
amount of radium is divided into eight parts
cylinder belt – 4 parts
and distributed according to the shape of the core – 2 parts
implanted volume as given in Table 14.9. For end – 1 part each (2)
cylinder, the belt defines the region around the
sphere shell – 6 parts
cylinder and the core refers to the placement core – 2 parts
of sources within in the center of the cylinder.
(2) The needles should be spaced as uniformly cuboids side – 1 part each (4)
end – 1 part each (2)
as possible with not more than 1.0 cm apart. core – 2 parts
There should be at least eight needles for the
belt and four needles for the core. (3) The
effective volume is reduced by 7.5% for each uncrossed end for the purpose
of determining the dosage from dosage table.
The other classical dosimetry system is referred as the Quimby system.

Edith Quimby in the United States developed a set of rules and tables for the
use of uniform activity needles of radium spaced uniformly in an implant
which is opposite to the philosophy of the Manchester system. Consequently,
the implant yielded non-uniform dose distribution in the treatment plane. For
planar implants, the Quimby tables give the number of milligram-hours
required to produce 1000 R at the center of the treatment plane, up to 3 cm
from the plane of the implant. The stated dose is therefore the maximum dose
in the treatment plane.12 The source should be distributed as uniform as
possible but no closer than 1 cm and no larger than 2 cm. For volume
implant, the stated dose is the minimum dose with the implanted volume.
The dosage tables are modified using the same elongation factors and filter
correction (2% per 0.1 mm Pt) as the Table 14.10 Patterson-Parker linear source
tables (mg-hr/10 Gy)
Patterson-Parker system.
Length Treatment Distance (cm)
Patterson and Parker had also (cm) 0.5 1.0 1.5 2.0
calculated the number of milligram-hours
in a radium source of active length L 1 41 136 295 517
needed to deliver 1000 R to a point A, h 2 59 162 320 546
4 100 234 417 650
cm from the source. Their result 6 146 316 530 789
converted to Gy by multiplying by 1.064 8 192 404 651 944
13 10 235 493 778 1109
is given in Table 14.10. Although
12 280 581 908 1272
Table 14.8 is of historical value, it can 14 326 671 1038 1442
also be used to estimate the dosage for a 16 371 761 1170 1615
single line source with minimal curvature 18 419 853 1302 1791
20 465 944 1438 1967
such as in endobronchial implantation
using other radionuclides Source filtered by 0.5 mm Pt.
EXAMPLE 14.10 A radiation oncologist estimated that the length of an enbronchial treatment
is 10 cm long. Calculated the activity per cm of Ir-192 needed to deliver 3000 cGy in 3 days
to a depth of 1.0 cm.
SOLUTION:
a) From Table 14.10, the number of mg-hrs needed to deliver 10 Gy is 493 mghrs.
b) The activity or mg per cm
30 Gy x 493 mg hr / 10 Gy 1
A x 2.1 mg / cm
3 d x 24 hr / d 10 cm
c) The activity conversion from mg/cm to mCi/cm
2
mg 8.25 R cm / mg h
A 2.1 x 3.77 mCi / cm
cm 4.6 R cm2 / mCih
Today, brachytherapy dosimetry is performed using computers that

provide (a) a more accurate dosimetry since it is based on the actual implant
(b) takes into account the short half-life and decay during delivery period, and
12
Glasser, O.; Quimby, E.H.; Taylor, L.S.; et al. Physical Foundation of Radiology. 3rd ed. New
York, NY: Harper & Row Publishing; 1967.
13
Johns, H.E.; Cunningham, J.R. The Physics of Radiology. 4th ed. Springfield, IL: Charles C
Thomas Publisher; 1983. Taken from Table 13.3.
(c) an immediate availability of complete dose distribution, which can be

displayed in any plane. The latter is especially useful for performing
permanent implants where the dose distribution is being created during
implantation process. This allows for possible modification of the implant
before the implant is completed. For temporary implants, a preplan allows
acquisition of the sources with appropriate strength or the optimization of the
dose distribution before loading the sources into the patient. The 3D
treatment planning system provides additional information on the dose
contribution to surrounding critical organ-at-risk and the generation of dose
volume histograms.
14.14 Strontium-90 Eye Applicator
Specialized applicator as shown in Figure

14.18 has been designed for the treatment of
pterygium. It is a benign eye disease exhibited as a
tissue extended to the front of the eye. At the end
of the applicator has a strontium-90 source which
is pure beta emitter. It has a half-life of 28 years
decays into yttrium-90 (90Y). In turn yttrium-90 Figure 14.18 Strontium-90
90 applicator
decays into zirconium-90 ( Zr) with a half-life of
64 hours. The maximum beta particle energy is
0.54 MeV while the yttrium-90 releases a more penetrating E-particle with
maximum energy of 2.27 MeV. There is a plastic circulator plastic above the
source to serve as shielding.
The strontrium-90 beta ray applicator is constructed in the form of a
plaque placed over the eye. The applicator is composed of strontium-90 in
foil bonded in silver and covered with 0.5 mm thick of polythene plastic to
absorb low energy beta rays. The backing of the foil is usually covered with
silver to absorb radiation. The applicator has a diameter of 10 – 20 mm
diameter. The dose rate is about 1 Gy/min at the surface of the applicator.
The dose to the lens is about 20% and the
treatment dose comes principally from the
2.27 MeV beta rays. The treatment is
performed by hand held placement of the
plaque over the eye surface for a short time in
seconds. The treatment schemes range from
20 – 60 Gy in 3 – 30 Gy per fraction.14 The
source is typically calibrated by NIST and the
dosimetry involves the correction for source Figure 14.19 Eye plaque mold
decay to determine the dose rate and
thereafter the calculation of treatment times.
14
http://www.aapm.org/meetings/05SS/program/pterygium072005_chiu.pdf
14.15 COMS Eye Plaques
In 1985, the Collaborative Ocular Melanoma Study (COMS) was

formed with the objectives of defining the optimal treatment for patients with
choroidal melanoma through multi-institutional trials.15 Patients who have
been randomly assigned to radiation treatment receive either radioactive eye
plaque or preoperative external beam radiation therapy depending on the size
and location of the tumor. The study was designed to compare the role of
radiotherapy and enucleation in the treatment of medium and large-size
choroidal melanoma.
The eye plaque as shown in Figure 14.19 is fabricated with various
sizes to fit over the globe of the eye as well
as the tumor. The plagues are available in
five diameters: 12 mm, 14 mm, 16 mm, 18
mm, and 20 mm. Each plaque consists of an
outer gold plaque and a flexible inner plastic
plague engraved with slots to accommodate
the iodine-125 seeds. As shown in the
figure, the eyelets on the outer gold plaque
allow for suturing to anchor the sources. The
radioactive seeds are sandwiched between
the inner and outer plagues. The plastic Figure 14.20 Eye plaque dose distribution
plaque is designed to allow 1.0 mm of plastic
between the seed and the scleral surface. This sandwich technique helps to
minimize the chance of seed
dislodgment. Since the geometrical Table 14.11 Dose rate at prescription point for 10
mCi seed strength
slots are defined for each plaque, the Distance Eye Plaque Size
dose distributions are the same (mm) 12 mm 14 mm 16 mm 18 mm 20 mm
among the patients using the same
size plaque except the prescription 5 178 276 259 400 429
7 114 181 175 278 304
point which varies with the tumor 9 78 125 123 199 221
size. 11 55 90 89 146 164
For tumor size between 3 mm 13 41 66 66 109 123
15 31 50 50 83 95
to 5 mm in apical height, the
prescription point is set as 5 mm from
the interior surface of the sclera. Prescribed dose for tumors greater than 5 mm
are defined at the tumor apex. For each prescription point, the seed strength has
to be adjusted to deliver the same radiation dose. Since the seed strength and
the prescription point are geometrically related, simple lookup tables would be
useful in determining the source strength and facilitate ordering the sources
once the tumor size and eye plaque are determined. The coordinates of the
seed sources for standardized eye plaques are available at the depository
site.16 The seeds are arranged in rings in a clockwise fashion from the outer to
15
http://www.jhu.edu/wctb/coms/general/publicat/pubs.htm
16
http://rpc.mdanderson.org/rpc/credentialing/COMS.htm
inner ring. The right-handed Cartesian coordinate system is used with origin
positioned at the center of the plaque. The positive X-axis points towards the
center of the eye and is Table 14.12 Seed strength (mCi) to deliver 85 Gy
perpendicular to the planar seed in 4 days
rings. It is a measure of the apical Distance Eye Plaque Size
(mm) 12 mm 14 mm 16 mm 18 mm 20 mm
height as shown in Figure 14.20.
Saw et al. had performed dose rate 5 5.09 3.28 3.50 2.27 2.11
calculations at the prescription 7 7.95 5.01 5.18 3.26 2.98
points as given in Table 14.11 for 9 11.62 7.25 7.37 4.55 4.10
11 16.48 10.07 10.18 6.21 5.53
iodine-125 seeds with source 13 22.10 13.73 13.73 8.31 7.37
strength of 10 mCi.17 At the time of 15 29.23 18.12 18.12 10.92 9.54
the publication, the COMS protocol
required a dose of 100 Gy at the
prescription point. For dosimetric reasoning discussed, the prescribed dose
was changed to 85 Gy. Using this prescribed dose and the treatment time of 4
days and 5 days, the seed strength Table 14.13 Seed strength (mCi) to deliver 85 Gy
can be computed and given in in 5 days
Distance Eye Plaque Size
Tables 14.12 and 14.13. The (mm)
calculations also accounted for seed 12 mm 14 mm 16 mm 18 mm 20 mm
strength decay during the treatment
given by the equation in Exercise 5 4.10 2.64 2.82 1.82 1.70
7 6.40 4.03 4.17 2.62 2.40
14.3 9 9.35 5.83 5.93 3.66 3.30
11 13.26 8.10 8.19 4.99 4.45
13 17.78 11.05 11.05 6.69 5.93
15 23.52 14.58 14.58 8.78 7.67
14.16 Gliasite
The GliaSite radiation therapy system (GSRTS) is an intracavitary balloon

catheter brachytherapy system designed for the management of surgically
resected brain tumors where adjuvant radiation therapy of the post-resection of
the tissue bed is indicated. The device
comprises of an inflatable balloon
connected to an infusion port by a
multilumen, silicone catheter shaft. After
the tumor resection, a deflated balloon is
placed in the surgical cavity with the
infusion port placed subcutaneously
accessible externally. One to three weeks Figure 14.21 Gliasite procedure
following post-surgery, the balloon is then [From:http://www.isoray.com]
inflated with iodinated contrast agent as shown in Figure 14.21 and confirmed
using either CT or MR imaging or both. If the balloon is adequately positioned,
it is loaded with sodium 3-[iodine-125]iodo-4-hydroxybenzenesulfonate in
sodium chloride solution. Delivered doses are in the range of 40-60 Gy at 40-
60 cGy/h (4 day implant) and at depth of 0.5-1.0 cm from the surface of the
17
Saw, C.B.; Seidel, M.; Pawlicki, T et al. Seed strength determination for eye plaque therapy.
Med Dosm 18: 3337; 1993.
balloon. Thus the device provides a homogeneity high dose to the edges of the
resection, with relative sparing of the neighboring tissues.
14.17 Prostate Seed Implantation
During the past decade, permanent radioactive seed implantation has

become the standard of care for early stage prostate cancers where the disease
is confined to the prostate capsule rather than radical prostatectomy, external
beam therapy alone, or high-dose-rate (HDR) brachytherapy. Although
invasive, prostate seed implantation is more popular in the United States
because it is a one time treatment rather than several weeks compared to
external beam radiation therapy. The techniques of implantation have
evolved in many different forms. Radioactive sources of iodine-125,
palladium-103, and cesium-131 have been used. These radioactive sources
produce different dose distribution and irradiate the tumor at different dose
rates. Prostate seed implantation involves three major steps: (a) volume study,
(b) transperineal seed implantation, and (c) post-implant dosimetry. Prior to
the volumetric study, a CT scan is taken to assess the size of the prostate and
its relation to the pubic arch. Prostate shrinkage via hormonal therapy may be
employed to avoid technical difficulty of pubic arch interfering with the
insertion of needles.
The volume study is performed
using transrectal ultrasonography (TRUS).
The patient is set up in the dorsal
lithotomy position with the knees and legs
in rigid stirrups and elevated. A transrectal
ultrasound device is anchored on the
patient table. An ultrasound probe
attached to the device is inserted into the
rectum in precise 5 mm steps to obtain
transaxial images of the prostate
superimposed on a grid as shown in Figure Figure 14.22 Volume study for prostate
implant
14.22. The volume study consists of a
series of transaxial images covering from the base of the prostate gland to the
apex in 5 mm increments. On each image, the prostate is outlined to create a
volume of the prostate. The transaxial images provide (a) a means of assessing
whether seed implantation is technically feasible and (b) patient information to
perform pre-implant dosimetry to order the number of seeds and its activity
per seed. Nomogram has also been used based on the three major axes of the
prostate on the ultrasound images to order the number of seeds. Depending
on the implantation techniques, either loose seeds or in pre-loaded needles
may be ordered. The typical seed strength is in the order of 0.3 mCi per seed
for iodine-125 for a minimal peripheral dose (MPD) of 145 Gy and 1.8 mCi
per seed for palladium-103 for an MPD of 120 Gy in monotherapy treatments.
The transperineal implantation technique is performed in the operation

room. The patient set up is basically the same as
for the volumetric study. Radioactive seeds are
inserted into the prostate under the guidance of
the transrectal ultrasonography and a grid
template with 0.5 cm grid spacing above the
ultrasound probe as shown in Figure 14.23. The
procedure is performed on an outpatient basis.
The grid template serves as a guide for the pre-
loaded needles or needles attached to the Mick
applicator to implant seeds into the prostate.
These needles are of the size 18-gauge and 21
cm in length. Loose seeds are preloaded into
spring-loaded cartridge called magazine. The
Figure 14.23 Grid and probe
magazine is then attached to the Mick applicator
for implantation. The applicator is then fixed at one end to the needles that
have been inserted into the lesion. The seeds are
deposited one at time at specified intervals along
the track as the needle is withdrawn by the
applicator. Pre-loaded needles typically are
ordered through third party are shipped sterile.
However, the seeds can also be loaded into the
needles in the operating room behind an L-shield
with spacers and then capped with a plunger at
the end. The radioactive seeds are intuitively
distributed so that ¾ of the sources are distributed Figure 14.24 Radiograph of
at the periphery of the prostate and also avoid implanted seeds
implanting the urethra. Following the implantation, a radiographic image is
taken as shown in Figure 14.24 for seed counting as well as documenting the
placement of the sources.
Once the patient is removed, the operating room must be surveyed
for dropped seeds or extracted from the
bladder. A radiation safety instructions sheet
on (a) how to handle radiation and accessible
seed sources and (b) contact information is
also given to the patient prior to his release
from the hospital.
EXERCISE 14.8 It is possible that a few seeds may be

dislodged into the bladder and later found in the urine
after the patient had been released. What action should
the patient take if to look for these seeds?
Figure 14.25 Post implant dosimetry
The quality of a permanent interstitial implant can only be evaluated by

performing post-implant dosimetry. However, the prostate is enlarged due to
the trauma of the implantation giving a false implant quality. The edema will
subside as a function of time. The AAPM report No. 137 recommended the
optimal time to perform post-implant dosimetry is 10 r 2 days for cesium-131,
16 r 4 days for palladium-103, and 1month r 1 week for iodine-125
implants.18 This assumes that (a) the prostate is stable after swelling already
subsided, and (b) seed positions are also stable to give a more realistic dose
distribution. The post-implant dosimetry is typically performed using CT
images as shown in Figure 14.25. The quality of the implant is evaluated
using criteria given in Table 14.14 taken from AAPM Report No. 137. At least
95% of the clinical target volume should receive the prescription dose and
less than 50% of the clinical target volume should receive 150% or more of
the prescription dose. The clinical target volume should receive 90% of the
prescription dose. The volume of the rectum that received the prescription
dose should be less than 2 cc. Table 14.14 Prostate quality index*
Index Criteria
V100 > 95% of CTV

14.18 Gynecological Dosimetry V150 < 50% of CTV
D90 > prescribed dose
Intracavitary brachytherapy commonly D2cc(rectum) < prescribed dose
D10 (urethra) < 150% prescribed
performed in gynecology is also referred to as dose
gynecological brachytherapy. The treatment
can be separated into three regions, the vagina, *From AAPM Report No. 137
cervix, and uterus. The applicator set used in
the treatment of the vagina is the cylinder set while the FSD applicator set for
the treatment of the uterine. Heyman capsule designed as a flexible plastic tube
with a bulbous end (capsule) at the tip to hold a source allow the ability to pack
and spread the sources in the form of a flower in the treatment of the uterus. In
the past, radium-226 sources were used and have been replaced with cesium-
137 for these temporary implants.
The commonly used applicator is the FSD applicator set as shown in
Figure 14.2. The FSD applicator made of stainless steel consists of two 2-cm
diameter and 3-cm high cylindrical ovoids (colpostats) fastened to separate
handles, which were locked together at scissor joint. The transmission through
the colpostats is reduced by 7%.19 Tungsten buttons or shields were inserted in
each end of the ovoid to shield the anterior rectal wall and trigone of the
bladder without decreasing radiation to the cervix, uterosacral ligaments, and
broad ligaments.20 The tungsten shield reduces radiation anywhere from 10 to
25%. Plastic jackets or caps can be added to the ovoid to increase their
diameter to 2.5 cm or 3.0 cm thereby reducing the radiation dose to the mucous
18
AAPM Report No. 137. AAPM recommendations on dose prescription and reporting methods for
permanent interstitial brachytherapy for prostate cancer: Report of the Task Group 137. College
Park, MD: American Association of Physicists in Medicine; 2009.
19
Haas, JS; Dean, RD; Mansfield, CM. Dosimetric comparison of the Fletcher family of
gynecologic colpostats 1950-1980. Int J Radiat Oncol Biol Phys. 11: 1317-1321; 1985.
20
Haas, JS; Dean, RD; Mansfield CM. Fletcher-Suit-Delclos gynecologic applicator: evaluation of
a new instrument. Int J Radiat Oncol Biol Phys. 9: 763-768; 1983.
membrane. Sources are inserted through the hollow handles to the ovoids to
implement the afterloading technique. The source has to be carried in a double
hinged “bucket” to undergo a sharp bend as it enters the ovoids which is
perpendicular to the handle. The tandem is a curved tubular device that is
inserted into the uterine and can accommodate one to four linear sources.
The tandem is curved 15, 30, 45, or 60 degrees to adapt to the curvature of the
cervix. A flange adjustable along the length of the tandem is set flush against
the cervical os. The Fletcher-Suit-Delcos (FSD) application consists of a tandem
inserted into the uterine canal and the colpostats placed at the fornices of the
cervix
The other type of applicator is the vaginal cylinder set as shown in Figure
21
14.26. The vaginal cylinder consists of plastic cylinder into which cesium-
137 tube sources can be inserted along its axis. The distal end of the cylinder is
usually rounded or dome shaped for
ease of insertion and to better fit the
vagina. The radioactive sources are
generally held in a metal tube that
extends outside the body so that the
cylinder can be afterloaded. A
commercial vaginal cylinder
developed by Delclos et al has the
vaginal cylinder segmented into 2.5
cm long. The appropriate length of
the cylinder can be assembled using Figure 14.26 Vaginal cylinder set
these segments. The set consists of
six cylinder sizes from 2.0 to 4.5 cm in increments of 0.5 cm and three uterine
tandems and a vaginal tandem. The purpose of increasing the cylinder size is to
decrease dose to the mucous membrane. The first cylinder to be mounted on
the tandem has a dome shape.
Implant dosimetry for gynecological brachytherapy has resulted in
having three different dose specifications. These dose specification systems are
the (a) milligram-hours, (b) Manchester system of points A and B, and (c) ICRU
recommendations.
One of the oldest dose
specifications for the treatment of cervix is
the milligram-hours. The milligram-hours
are determined as the product of the total
source strength expressed in mg-Ra eq and
the duration of the implant time expressed
in hours. Because of the extensive clinical
data accumulated especially with the use
of FSD applicators, the use of milligram-
hours dose specification has continued. Figure 14.27 Definition of point A and B
The milligram-hours dose specification in the Manchester system.
21
http://www.teambest.com/products.html
describes neither the source arrangement nor the packing of the sources relative
to the tumor and patient anatomy.
The Manchester system of dose specification is extensively used around
the world. The system attempted to express the implantation from a physical
point of view so that the doses at points in the pelvis can expressed in terms of
roentgen. The point of tissue tolerance was defined in the paracervical triangle
defined as point A. This point is situated at 2 cm laterally from the uterine canal
and 2 cm above the lateral fornix as illustrated in Figure 14.27. It is a point
where the uterine vessels cross the ureter. Another useful point is called point B
is situated at 5 cm from the midline at the same level as point A. This point is
often used to boost by external beam therapy. In clinical practice, point A is
determined to be 2 cm up from the flange of the intrauterine source and 2 cm
lateral from the central canal. In addition to point A and point B, the doses to
the rectum and bladder are also calculated.
EXERCISE 14.9 Explain how to determine point A, point B, rectal dose point, and bladder dose
point are defined in a clinical case.
The doses to points A and B have been correlated to the prescription

using cumulated activity expressed in milligram hours. The correlation is weak
since the dose DA point A and the dose DB point B are dependent on the source
arrangement, the arrangement of the applicator and the extent of the tumor.
The correlation can be approximated as
~
DA 0.78 A
~ (14.25)
DB 0.24 A
where doses are expressed in cGy and cumulated activity in mg-hrs.22
EXAMPLE 14.11 A FSD insertion was performed in a gynecologic case to deliver 4000 mg-
hrs of treatment. What is the estimated dose to points A and B
SOLUTION:
a) Dose to point A:
~
D A 0.78 A ( 0.78 cGy / mg hr )( 4000 mg hr )
3120 cGy
b) Dose to point B
~
D B 0.24 A ( 0.24 cGy / mg hr )( 4000 mg hr )
960 cGy
22
Cunningham, DE et al. A comparison of mg-hr prescription to doses at points A and B in cervical
cancer. Int J Rad Oncol Biol Phys 7: 121-123; 1981.
Gynecology brachytherapy is often given in combination with external

beam. It would be desirable to combine the concepts used in external beam
into implant therapy. In 1985, the International Commission on Radiation Unit
and Measurements published Report No. 38 that attempted to deal with this
subject matter for reporting intracavitary
dose for gynecology23. The ICRU Report
No. 38 recommended that the dose be
prescribed as an isodose surface that
surrounds the target volume instead of
target points. The ICRU also has the
criteria of defining the bladder and rectal
point. The bladder dose point is taken at
the bottom of a Foley balloon directly
beneath the center as seen on the lateral Figure 14.28 ICRU reference points of
the bladder and rectal dose.
radiograph and at the center of the
balloon on the anterior-posterior
radiograph. The Foley balloon is positioned by injecting 7 ml of radio-opaque
fluid to expand and pull down the balloon against the urethra as illustrated in
Figure 14.28. The rectal dose point is taken as the point directly below the
lower end of the intrauterine source and 5 mm behind the posterior vaginal
wall. The posterior vaginal wall can be seen on the lateral radiograph by
packing the vaginal cavity with radio-opaque gauze.
14.19 Quantitative Assessment of Interstitial Implants
Interstitial implants in the form of a single-plane, double-plane, or

volume involve the systematic placement of radioactive seeds uniformly
throughout the target volume. The aim of the uniform seed distributions is to
generate a homogenous dose distribution throughout the implant. Unlike
external beam radiation therapy, the concept of homogeneous dose distribution
is difficult to define since doses closer to
the seeds are expected to be very high and
then falling off as the inverse square of the
distance from each seed.
In the past, the quality of an
implant was judged based on isodose
distributions in a few planes. For the
Manchester system, the plane is taken to
be at 0.5 cm away from the implant
plane. For computer-based dosimetry, Figure 14.29 Differential DVH of a
the plane pass through the central part double-plane implant.
and perpendicular to the implant plane is
23
ICRU Report No. 38. Dose and Volume Specification for Reporting Intracavitary Therapy in
Gynecology. International Commission on Radiation Units and Measurements. Bethesda, MD;
1985.
used for evaluation and dose rate prescription. The isodose rate line at a
defined distance and encloses the implant is often chosen as the prescribed
dose rate. With the accessibility of 3D treatment planning system, it is
possible to quantify the dose variation across an implant.24 Figure 14.29 is a
differential dose volume histogram (DVH) of an ideal double-plane implant
with plane size of 8 cm x 8 cm and plane separation of 1.5 cm. 25 Differential
dose volume histogram refers to a plot of dose volume receiving a range of
dose rate as a function of reference dose rate. The general feature of this dose
volume histogram is the increase in volume as the dose rate decreases
indicating a small volume receiving very high dose near the sources. The
asymptotic behavior of the curve represents the inverse square characteristic
of the sources. Superimposed on this smooth function is a peak indicating a
large volume receiving a small range of dose rates. The width of the peak
would give an indication of the uniformity of the implant. A small magnitude
and a broad peak would represent a poor implant configuration while a good
implant would give a large magnitude and a narrow peak. This distinct
feature is not apparent in the cumulative DVH.
Lowell Anderson recognized the shape of the DVH is in part due to the
inverse square effect.26 To remove the inverse square effect, Anderson
introduced a differential “natural” dose volume histogram for interstitial
brachytherapy. The “natural” dose volume histogram is a plot of the
distribution of volume per unit –3/2 power of dose rate versus the –3/2 power
of the dose rate. For a point source, the plot would be a constant as derived
below.
EXAMPLE 14.12 Show that the differential “natural” dose volume histogram for a point
source is a constant.
SOLUTION:
For a point source, the dose rate at a location r distance from a point source with
strength S is given as
1/ 2
S S
D or r
r
2 1/ 2
D
and
1/2 3 / 2
dr ½ S D dD
The dose rate at a distance r is related to a spherical-shell volume element as
24
Saw, CB; Suntharalingam, N; Wu, A. Concept of dose nonuniformity in interstitial brachytherapy.
Int J Radiat Oncol. Biol Phys 26:519-527; 1993.
25
Saw CB; Suntharalingam, N. Quantitative assessment of interstitial implants. Int J Radiat Oncol.
Biol Phys 20:135-139; 1991.
26
Anderson, LL. A “natural” volume-dose histogram for brachytherapy. Med Phys 13:898-
903;1986.
2
dV 4 Sr dr
S 1/2 3 / 2 ) 5 / 2 dD
3/ 2
4S ( ½ S D dD 2 SS D

D
A function u is defined with the –3/2 power dose rate is defined as
u 3 / 2 D
D 3 / 2
o
and
du 3 5 / 2 dD

2D
The differential “natural” dose volume histogram is a representation of dV/du is
dV 2SS
3/ 2
D 5 / 2 dD

3/ 2
4 3 SS
du 3 5 / 2 dD
D
2
which is independent of the dose rate.
Using the “natural” dose volume histogram, adding sources would lead to the
formation of a peak and hence showing the dose rate uniformity as depicted in
Figure 14.30. The peak width, peak position and contained volume relative
to the treatment dose rate would
provide a quantitative assessment of an
interstitial implant. Although the
“natural” dose volume histogram
provides a detail assessment of an
interstitial implant, it seems complex for
clinical use. Several quantitative
indices that use simple numeric values
have been proposed for the assessment
of interstitial implants.
One of the quantitative indices
proposed is the dose nonuniformity Figure 14.30 A differential “natural” dose
ratio (DNR).27 It is defined as the ratio volume histogram.
of two volumes, a high dose volume to
a reference volume.
Vhdr
DNR (14.26)
Vrdr
where Vhdr is the high dose volume is defined as the volume receiving at least
1.5 times the reference dose rate and Vrdr is the reference volume, the volume
27
Saw, CB; Suntharalingam, N; Wu, A. Concept of dose nonuniformity in interstitial brachytherapy.
Int J Radiat Oncol. Biol Phys 26:519-527; 1993.
receiving at least the reference dose rate. For a point source, the DNR has a
constant value.
EXERCISE 14.10 Show that the DNR for a point source is independent of dose rate.
A plot of the DNR versus the reference dose rate shows a minimum as shown
in Figure 14.31. This minimum represents the small high dose volume within
a reference volume and hence the
optimal dose uniformity for an implant.
For very low and very high reference
dose rates, the DNR value approaches
that of the single point source as the
isodose surfaces is spherical around the
whole implant or around each source.
Whether an isodose distribution
conforms to a target can be assessed
using the three irradiation indices which
are based on the knowledge of the
location and the extent of the target Figure 14.31 DNR of a two plane
volume.28 The coverage index (CI) is a interstitial implant.
measure of the fraction of the target
volume receiving dose rates equal to or greater than the reference dose rate.
The external index (EI) quantitates the amount of tissue external to the target
volume, expressed as a percentage of the target volume, that receives dose
rate equal to or greater than the
reference dose rate. The relative dose
homogeneity (HI) index measures the
fraction of the target volume receiving
dose rates in the range of 1.0 to 1.5
times the reference dose rate. The
behavior of these indices as function of
reference dose rate for the double-plane
iridium-192 implant is illustrated in
Figure 14.32. The CI value decrease
and hence the coverage of the target
volume as the reference dose rate
Figure 14.32 The volumetric indices for
decreases. Correspondingly, the EI
double-plane implant
value representing the volume of tissue
outside the target that is irradiated to higher dose rate than the reference does
rate also decreases. On the other hand, the HI value exhibits a peak value
implying that the dose homogeneity within the target volume is optimized at
this reference dose rate. In an ideal implant, one expects to have complete
28
Saw CB; Suntharalingam, N. Quantitative assessment of interstitial implants. Int J Radiat Oncol.
Biol Phys 20:135-139; 1991.
coverage of the target volume with a homogenous dose distribution with no

tissue outside the target volume receiving doses exceeding the treatment dose.
Such an ideal implant will have both the CI and EI values equal to 100% and
the EI value to be zero at a particular treatment dose rate. However, the
physical characteristics of interstitial implants are such that it is not possible to
achieve this ideal condition.
14.20 Radiobiology Considerations of Brachytherapy
Compared to external beam radiation therapy, the principal advantages

of brachytherapy are (a) excellent dose distribution, (b) short overall treatment
times, and (c) low dose rate. By excellent dose distribution, it is meant that the
dose distribution is highly conformal or localized and hence minimizing
radiobiological damage to normal adjacent tissues. There is no concern of
underlying and overlying normal tissues being irradiated in brachytherapy.
Brachytherapy therefore spares (a) early-responding normal tissues which in
external beam therapy would prolong treatment time, and (b) late-responding
normal tissue, which in external beam therapy represent the dose-limiting
endpoint. Short overall treatment times are indicated for brachytherapy since (a)
long overall treatment times are known to cause of local failure because of the
accelerated cell repopulation during treatment, and (b) the effect of short overall
treatment times on early-responding normal tissues is minimal since the implant
geometry allows for sparing of these tissues. It is well known that lowering the
dose rate generally results in a reduction in radiobiological damage providing
the opportunity for sublethal damage repair of the late responding normal
tissues. On the other hand, increasing the dose rate will increase the late effects
much more than it will increase tumor control. Thus the therapeutic ratio (i.e.
the ratio of tumor control to complications) will increase as the dose rate
decreases.
Brachytherapy is characterized by the continuous dose delivery either
over a short treatment time or the life time of the source to a complete decay.
For temporary implants, the dose rates are in the range of 0.3 – 0.9 Gy/h for 3 –
7 days. Paterson published an isoeffect curve indicating the deliver y of 60 Gy
in 7 days.29 On the other hand, permanent implants deliver a high total dose
at a very low dose rate over several months. Cesium-131, iodine-125,
palladium-103 are being used in the treatment of prostate carcinoma. The
initial dose rate of cesium-131 is about 0.34 Gy/h which is about 1.5 times
and 5 times higher that of palladium-103 and iodine-125. Ninety percent of
the doses are delivered in 32 days for cesium-131, 56 days for palladium, and
198 days for iodine-125.
EXAMPLE 14.13 Compute the number of days needed to delivered 90% of the monotherapy
dose of 115 Gy for a cesium-131 permanent implant to the prostate.
SOLUTION:
29
Paterson R. Studies in optimum dosages. Br J Radiol 25: 505; 1952.
(a) The ratio of a percentage dose delivery to complete dose delivery is given as
D% 1.44 WD0 ª¬1exp
1.4 exp(( 0.693t / W º¼
D100 1.44 WD0
(b) For 90% dose delivery, the equation becomes

0.9 1 exp( 0.693t / W)
9.7d x ln(1 0.9)
t 31.2 d
0.693
During the decay, the relative biological effectiveness (RBE) increases as the
dose rate decreases. The radiobiology due to dose rate effect has been
explained in earlier published textbook.30 Another inherent characteristic of
brachytherapy is the very heterogenous dose distributions. While the dose is
prescribed to an isodose line that encircles a small target volume, the dose
and dose rate within the target volume are much higher especially in the
vicinity of each source. The average dose given to the target volume is always
higher than the prescribed dose. These doses are even higher than the
tolerance dose levels accepted in external
beam therapy and yet, the procedure is
well tolerated because of the volume-
effect relationship (very small volumes
can tolerate very high dose levels).
Because of the small volume requirement
for this procedure, only about 10 –20% of
all radiation therapy patients are treated
with brachytherapy.
Figure 14.29 Differential DVH of a
double-plane implant.
14.20 Management of Patients Undergoing Brachytherapy
Whenever a patient undergoes brachytherapy and requires

hospitalization, certain radiation protection procedures must be implemented.
The patient must be placed in an isolated room. Radiation protection
procedures should include (a) making aware to the staff and public that radiation
protection rules are invoked for that isolated room, (b) staff and public (family
members) entering the isolated room should be managed for radiation
exposures, (c) the radiation sources used must be tracked in the inventory
logbook, and (d) when the treatment is complete and sources removed, the
room must be declared safe.
To ensure awareness, radiation area and radioactive material signs
should be posted in front of the door into the isolated room. In addition to
posting at the door, radiation area and radioactive signs are also posted on the
patient chart. The amount of radioactive materials used and also the measured
exposure should be included in the postings. An instruction on the care of the
30
Saw, C.B. Foundation of Radiological Physics. Omaha, NE: C.B.Saw Publishing, 2004. Chapter
15 – Radiobiology.
patient undergoing brachytherapy should be attached to the chart. There should

also be available a radiation monitoring record sheet and personnel monitoring
device. Nursing staff caring for brachytherapy patients should undergo radiation
protection training annually.
Any person entering the isolated should be monitored for radiation
exposure using the provided personnel monitoring device or assigned radiation
badges. For family members, there is time limitation for the visit and the
minimal distance to the patient based on measured exposure from the implant.
Persons under the age of 18 or pregnant are not allowed to visit the patient.
EXERCISE 14.11 Which parameters are used to determine the visitor’s stay time?
After completing the treatment, the radiation sources are returned to the
storage room. The transportation of the radioactive sources to the patient and
returned must in a shielded pig to limit radiation exposures to the public. The
isolated room and soiled materials are then surveyed and declared clear of
radiation exposure. Radiation warning postings and instructions are then
removed from the front door and patient’s chart.
Summary
14.1 Brachytherapy refers to the radiation treatment where sealed radioactive sources are
placed near or implanted directly into the tumors. The principal advantage of
brachytherapy has been its rapid dose fall-off as a function of distance from the sources.
14.2 The introduction of afterloading techniques followed by remote afterloading systems

has virtually eliminated radiation exposures to staff and public. With this
introduction, manual brachytherapy in particular temporary implants are rarely
performed.
14.3 Afterloading devices provide (a) pathways for the insertion of radioactive sources and
(b) a means to isolate the source from the patient to avoid contamination.
14.4 Depending on the applications, brachytherapy procedures are called differently such
as mold therapy for superficial treatment, interstitial treatment for tissue treatment,
intraluminal therapy for treatment of the lumen, and intracavitary therapy for the
treatment of lesions in body cavity.
14.5 If the sources are left permanently inside the patient for the duration of the decay, the
implant is called a permanent implant. Otherwise, it is called a temporary implant.
14.6 The strength of a brachytherapy source has been expressed in terms of (a) milligram
radium equivalent, (b) apparent activity in dps and (c) and air kerma strength in U.
14.7 Currently used brachytherapy sources are (a) cobalt-60, (b) cesium-137, (c) iridium-
192, (d) iodine-125, (e) palladium-103, and (f) cesium-131.
14.8 Brachytherapy sources are constructed (a) to provide source rigidity, (b) to contain
radioactive through sealed and encapsulation, (c) radiographically visible. The
encapsulation absorbs a substantial charge particle and low-energy photon
components, which would otherwise cause radiation necrosis adjacent to the source.
As a result of the filtration, the dosage is delivered principally from the high-energy
gamma components.
14.9 Iodine-125 seeds have been produced by a number of vendors. The seed is fabricated
by allowing iodine-125 to be absorbed in spheres or coated onto material. The
material together with radio-opaque markers is encapsulated to form a seed with 4.5
mm in length and 0.8 mm in external diameter.
14.10 Brachytherapy sources are typically calibrated using specially designed well-counter
with source holders.
14.11 In the past, the dose distribution around a brachytherapy source was computed based
on equations taking into account the attenuation through the encapsulation or using
point source approximation. The parameters used are the activity, the exposure rate
constant, the exposure-to-dose conversion factor, the tissue attenuation factor and the
anisotropy constant.
14.12 Based on the current TG-43 dosimetry formalism, the dose at a point is calculated
using the air kerma strength, the dose rate constant, the geometric factor, the radial
dose function, and the anisotropy function.
14.13 Before the dose distribution around an implant can be computed, the location of
individual sources must be determined. Typically the source locations are simulated
using dummy sources inserted into the applicator and radiographs are taken. The
source locations are determined based on the radiographs. There are a number of
algorithms to determine the seeds including the stereo-shift, orthogonal, and variable
angle methods. Image-based technique of determining the seed location is now being
used.
14.14 In the current practice of brachytherapy, the dose distribution is computed using
computerized brachytherapy treatment planning system. Once the source positions
are defined based on source localization techniques, the dose at point is the sum of
the contributions from each source.
14.15 The isodose around a source is characterized by a dip at the ends of the source. This
is due to the extra attenuation through the encapsulations.
14.16 The historical implant dosimetry systems are the Paterson-Parker and Quimby
systems. Paterson-Parker used non-uniform distribution of activities to achieve a
uniform dose distribution in the specified region. On the other hand, the Quimby
system used uniform distribution of activities and hence produced non-uniform dose
distribution in the specified region.
14.17 Manual brachytherapy are limited to a few implants such as the (a) Strontium-90 eye
applicator, (b) COMS plaques, (c) Gliasite, and (d) prostate seed implants.
14.18 Iodine-125, palladium-103, and cesium-131 are used for prostate seed implantation.
The prescribed peripheral doses for monotherapy are 145 Gy for iodine-125, 125 Gy
for palladium-103 and 115 Gy for cesium-131.
14.19 The steps of performing prostate seed implants consists of (a) volumetric study to
determine the number of seeds needed to be ordered, (b) assaying of the seeds, (c)
implantation of the seeds, (d) radiation survey of operating room, (e) instructions of
handling radioactive sources to the patient, and (f) post-implant dosimetry.
14.20 The applicators used in gynecological treatment are the vaginal cylinder applicator,
Fletcher-Suite Delclos, or needle templates. The purpose of the needle templates is to
places sources further away from the body cavity.
14.21 Gynecological dosimetry is basically based on two special points called point A and
point B. Point A refers to the point where the uterine vessels cross the ureter. On the
other hand, point B represents the location of the obturator nodes attached to the
pelvic wall.
14.22 The quality of an interstitial implant can be assess using the ratio of two volume such
as the dose nonuniformity ratio (DNR) or relative to the target as the coverage index,
the dose homogeneity index, and the external volume index.
14.23 The radiation dosage delivered for LDR brachytherapy is generally between 3-7 days
at a dose rate of 40-60 cGy/hr. The combined low dose rate and overall short
treatment time has some radiobiological advantages over conventional fractionated
external beam radiation therapy.
Study Guide
14.1 Define in your own words the following terms:

(a) brachytherapy (b) sealed source
(c) preloading technique (d) afterloading technique
(e) superficial implant (f) interstitial implant
(g) intracavitary brachytherapy (h) intra-luminal implant
(i) temporary implant (j) permanent implant
(k) milligram radium equivalent (l) exposure rate constant
(m) content activity (n) apparent activity
(o) air kerma strength (p) source localization
(q) mick applicator (r) seed magazine
(s) oviods (t) tandem
(u) Heyman capsules (v) DNR
14.2 Identify the unique feature of brachytherapy.
14.3 Identify the advantage of afterloading technique over preloading technique.
14.4 Identify two characteristics that make an isotope suitable for permanent implants.
14.5 Explain the difference between exposure rate constant and specific gamma ray
constant.
14.6 Give two reasons why radium-226 and radon-222 are considered hazardous.
14.7 List the isotopes that are commonly used for (a) permanent implants, (b) temporary
implants and (c) intracavitary implants.
14.8 List the half-lives of (a) cesium-137, (b) iridium-192, (c) gold-198, (d) iodine-125, (e)
californium-252, and (f) strontium-90.
14.9 Why the dose distribution around an iodine seed is attenuated at its end?
14.10 What kind of device is used to calibrate a radioactive seed?
14.11 Explain why the exposure rate from a point source is higher than a line source. Why
is point source approximation used for seed sources instead of linear source
formalism?
14.12 Give situations where the absorption and scatter function are ignored. Discuss in
terms of radionuclide characteristics and the region where the dose distributions are
of interest.
14.13 Explain why point source approximation is not used to compute the dose rate for
cesium source having a physical dimension of 2.0 cm, 1.4 cm active length in
intracavitary brachytherapy?
14.14 Give the rationales why TG43 dose calculation formalism was introduced?
14.15 Identify a geometric arrangement where three seeds appear as two seeds on
orthogonal radiographs. Describe how this seed arrangement can be resolved using
three-film technique.
14.16 Describe the general dose distribution of a 2 cm linear source.
14.17 Where is the dose uniformity stated in the planar implants according to the Paterson-
Parker system of interstitial implant?
14.18 Identify the fundamental difference between the Paterson-Parker and Quimby systems
of interstitial implantation.
14.19 Identify the location and the use of the flange on the FSD applicator.
14.20 The vaginal cylinder is commonly used to treat a particular site of the reproductive
organ. Identify this site.
14.21 Identify the disadvantage of using milligram-hours as a method of specifying a

treatment.
14.22 Define point A and point B. What do they represent?
14.23 Identify the difference between the “natural” dose volume histogram and the dose
nonuniformity ratio (DNR).
14.24 What is the difference between the DNR and irradiation indices?
14.25 A patient was initially treated with a FSD application. Additional dose will be
supplemented using external beam therapy with mid-line block. Explain the
advantages and disadvantages of using this technique.
14.26 Identity three advantages of low dose rate brachytherapy over external beam radiation
therapy.
14.27 The RBE of cobalt-60 is one while the RBE of iodine-125 is 2.0 and 10% more for
palladium-103. Explain
Problems
14.1 A patient was implanted with 88.5 mCi of cesium-137 for intracavitary therapy.
Express this amount in terms of mg radium equivalent.
14.2 An iridium-192 source has an exposure rate of 2 mR/hr at 1 m. What is the mg-
radium equivalent strength?
14.3 Ten iodine-125 seeds were measured individually and averaged. The air kerma
strength per seed was determined to be 0.691 PGym2/h. Find its equivalence in mCi.
14.4 Compute the air kerma strength of 15 mCi of iridium-192 and expressed it in U unit.
The exposure rate constant of iridium-192 is 4.60 R cm2/mCi-h.
14.5 If the exposure rate constant of iridium-192 is 4.69 R-cm2/mCi-h, show that the air-
kerma rate constant is 0.111 PGy m2/MBqh.
14.6 A preplan for an implant is done using an activity of 1.0 mCi per seed. The 70 cGy/hr
isodose level is selected for the dose prescription. What seed activity should be
ordered in order to deliver a dose of 50 Gy in 5 days?
14.7 An iridium-192 line source 6 cm long was used to deliver a dose of 30 Gy to a point 1
cm away. Assuming a linear activity of 2 mCi/cm, determine the treatment time using
linear source table (Table 14.10).
14.8 Iodine-125 and palladium-103 seeds are used in permanent prostate implants. What
are the initial dose rates if the iodine-125 implants delivers 145 Gy and 125 Gy for
the palladium-103 implants. Compare these dose rates to temporary implant dose
rates.
14.9 Typical initial dose rate of palladium-103 implants is about 0.21 Gy/h and iodine-125
implant is about 0.07 Gy/h. Draw a graph of the dose rate decay as a function of
time. Which implant would deliver the most doses in the shortest time?
14.10 Estimate the error in the dose rate in a plane that bisects a 0.5 cm line source at a
distance equal to twice dimension of the source (1.0 cm).
14.11 If the total decay of iodine-125 is 490 cGy at 2 cm using the MED3631-A/M seed,
what is the initial source strength in U?
14.12 A patient was treated to a dose of 40 Gy to point A using FSD insertion. What is the
estimated cumulative activity and dose to point B?
14.13 Compute the number of days required to deliver 90% of the total dose if the prescribed
doses are 125 Gy and 100 Gy for monotherapy and combined therapy.
Multiple Choice Questions

Choose one correct answer.
14.1 The technique where applicators or plastic tubes are introduced and later loaded with
radioactive sources is called
a) manual technique
b) preloading technique
c) afterloading technique
d) postloading technique
e) remote loading technique
14.2 An advantage of using afterloading devices is the reduction of exposure to all

individuals EXCEPT
a) surgical staff
b) transportation personnel
c) radiation oncology staff
d) public
e) medical oncologist
14.3 Which of the following radioactive source has smallest HVL

a) cesium-137
b) iridium-192
c) iodine-125
d) gold-198
e) radium-226
14.4 The HVL of these radionuclides in increasing thickness are

a) iodine-125, gold-198, cesium-137, radium-226
b) iodine-125, gold-198, radium-226, cesium-137
c) iodine-125, cesium-137, gold-198, radium-226
d) cesium-137, iodine-125, gold-198, radium-226
e) gold-198, iodine-125, cesium-137, radium-226
14.5 The exposure rate at 1 meter from a gynecological patient implanted with 100 mg-Ra-
eq of cesium-137 source is approximately:
a) 40 mR/h
b) 80 mR/h
c) 40 R/h
d) 8 R/h
e) 800 mR/h
14.6 Which statement is NOT true of cesium-137?

a) The half-life of cesium-137 is 30 years
b) The beam quality does not change with depth of penetration because of the single
photon energy
c) The source must be decayed quarterly
d) Cesium-137 is also used for permanent interstitial implant
e) Cesium-137 is used as a replacement to radium-226
14.7 The decay of a radioactive source was recorded

Table 14.15 Decay of a source
every six month as tabulated in Table 14.15.
Date Source Strength
This decay characteristics describes
a) cesium-137
Jun 1979 15.2 mgRaeq
b) iridium-192
Dec 1979 15.0 mgRaeq
c) iodine-125 Jun 1980 14.9 mgRaeq
d) gold-198 Dec 1980 14.7 mgRaeq
e) radium-226 Jun 1981 14.5 mgRaeq
Dec 1981 14.3 mgRaeq
14.8 The rapid dose falloff around an Iodine-125
source is primarily due to
a) tissue attenuation
b) inverse square effect
c) low energy radiation
d) dose build-down
e) encapsulation
14.9 Which of the following statement is not true about TG43 dose calculation formalism?
a) it is based on measured or measurable quantities
b) its application is limited to iodine-125, iridium-192, cesium-137
c) the parameters used are different from those used in the traditional dose formalism
d) it uses a dose rate constant instead of exposure rate constant
e) none of the above
14.10 Associate the sources with the linear source dose calculation formalism.
I. radium-226
II. cesium-137
III. iodine-125
IV. palladium-103
V. iridium-192
a) I and II
b) II and V
c) II, III, and IV
d) III and IV
e) V
14.11 A prostate implant was performed using iodine-125 sources (W=60 days) to deliver a
minimum tumor dose of 100 Gy. Due to a complication the patient died after 30
days. The dose received by the tumor under these circumstances is approximately:
a) 100 Gy
b) 50 Gy
c) 30 Gy
d) 20 Gy
e) 10 Gy
14.12 Given that the exposure rate constant for iridium-192 is 4.6 Rcm2/mCih, which of the
following exposure rate per mCi is INCORRECT?
a) 4.6 R/h at 1 cm
b) 184 mR/h at 5 cm
c) 5.1 mR/h at 30 cm
d) 0.46 mR/h at 100 cm
e) 0.046 mR/h at 1 m
14.13 Brachytherapy has advantages over external beam radiation therapy EXCEPT
a) lower dose rate irradiation
b) shorter overall treatment time
c) rapid dose fall off away from the implant
d) no concern of overlying tissue
e) lower exposure to personnel
14.14 Which of the following procedure should be performed when managing a

hospitalized brachytherapy patient?
a) transport radioactive sources in shielded pig
b) posting radiation precaution sign at door and patient’s chart
c) radiation survey the patient room
d) log out and in radioactive sources at storage inventory logbook
e) ALL of the above

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Therapeutic Radiological Physics (Version2013 - C.

Brachytherapy has been practiced since the discovery of radioactivity by

staff and public. As such manual brachytherapy in particular, temporary

14.1 Brachytherapy Terminology

A wide variety of applicators, afterloading catheters, and templates are

button and a flexi-needle used in interstitial implants.1 The catheters are

term plesiotherapy is sometimes used for close proximity placement of

14.2 Source Strength Specification

Over the years, the strength of brachytherapy sources has been

strength of the source expressed in milligram radium equivalent. From

The exposure rate constant refers to the exposure rate at a reference

constant (*x) takes into account only x- aExpressed in mg

The radiation exposure can be calculated based on the knowledge of

0.876 x 102 Gy / R PGy/R

where *AKR has the unit of PGym2GBq-1h-1 with *G in unit of Rm2Ci-1h-1.

PGy  m2 cGy  cm2

The relationships or conversion factors between source strengths in U and

14.3 Brachytherapy Source Characteristics

choice of radioisotopes for brachytherapy depends on a number of factors

Figure 14.5 Isointensity around an

The concept of cumulative dose is basically the same as the cumulative

The concept of complete decay is important in permanent implants where the

14.5 Calibration of Brachytherapy Sources

According to NRC (part §35.432) regulatory guidelines, the output or activity

arrangement approximates the point source geometry. The arrangement

to 14.7 psi, the chamber does not need

of the ion chamber is typically made of

applied can be 150 or 300 volts collection

Well-type chambers will respond to scatter radiation. When used, they

14.6 Dose Calculations of a

14.7 Point Source Approximation

Equation (14.13) provides a method of computing the exposure rate of a linear

Figure 14.10 shows a comparison 5 Point Source

Relative Exposure Rate

cm linear source as a function 3

the same. At shorter distance, 0

14.8 Traditional Dose Calculation Formalism

The traditional dose calculation formalism used in brachytherapy for

( r) A app (*G ) x g med T(r) Ian

It is fitted to a polynomial of the 1.0

Tissue Attenuation Function

form 0.9 cesium-137

attenuation factor, exposure-to-dose conversion factor and anisotropy factor.

which is an inverse square factor since ro = 1 cm. The radial dose

distribution around the source, including the effects of absorption and

14.10 Methods of Source Localization

In order to perform dose calculations following either the traditional or

above the film plane can be

above the film plane as Figure 14.13 Stereo shift technique

These two equations can be used to solve for h as

Substituting into equation (14.21), the z-coordinate of individual source in an

EXERCISE 14.7 Derive equation (14.23).

Orthogonal radiographic technique is the preferred method of source

shown in Figure 14.14 are commonly

(simulator unit) or along the direction

L (X2 X1)2 ( Y2 Y1)2 ( Z2 Z1)2 (14.24)

where notation 1 and 2 represent each end of a linear source.

14.11 Isodose Curves

where AKR has the unit of PGym2GBq-1h-1 with G in unit of Rm2Ci-1h-1.

PGy m2 cGy cm2