Dosage Systems of Brachytherapy

Practice
Presenter – Dr. Deep Sikha Das
Moderator- Dr. B. Arunkumar Sharma
Date- 7/6/2019
Introduction
• Brachytherapy (BT) (brachy is Greek for “short distance”) -
consists of placing sealed radioactive sources very close to or
in contact with the target tissue.
• The absorbed dose falls off rapidly with the increasing distance
from the source, allowing high doses to be delivered to a
localized target over a short time period.
• Until the 1960s, the sources were implanted directly to the
patient.
• Then came the manual afterloading technology
• Finally the remote afterloading system where the applicators
were inserted first followed by the loading of sources.
ADVANTAGES
• High radiation dose to a localized volume: high local
control.
• Spares surrounding normal organs and tissues.
• Ultimate form of conformal radiotherapy.
• Shorter treatment time, convenient and prevents tumor
proliferation.
• Non-homogenous dose distribution, targeting the
hypoxic central core.
DISADVANTAGES
• Invasive
• Expertise, equipment and experience.
• Difficult to maintain uniformity across various centres.
• Time consuming.
Brachytherapy sources
ISOTOPE ENERGY FORM HALF APPLICATION
Mev LIFE
Radium Ra226 avg 0.83 Tubes, Needles 1600 yrs IC, Interst.LDR
(Historic)
Cs-137 0.66 Tubes, Needles , 30 yrs IC, Interst. LDR
seeds
Co-60 1.25 Tubes, Needles , 5.26 yrs IC, Interst. HDR
seeds
Ir-192 avg 0.39 Wire, Pellets 74 days IC, Interst.intravas
HDR
I-125 0.028 Seeds 60 days Interst. permanent

Sr-90 0.2 Plaque,seeds 3.8 days Opthalmic,

Pituitary, Coronary
Au-198 0.42 Seeds 2.7 days Interst. permanent

Pd-103 .02 seeds 17 days Interst,permanent

Ideal Brachytherapy Source
• 1. Gamma ray energy should be optimum in range of 0.2 to 0.4 MeV.
• 2. Half life should be such that correction for decay during treatment is
minimal.
• 3. Absence of charged particle emission or it should be easily screened.
• 4. No gaseous disintegration product to prevent physical damage to the
source and avoid contamination.
• 5. High specific activity and adequate photon yield.
• 6.Material should be in insoluble and non toxic form.
• 7. Material should not be in powder form.
• 8.The sources can be made in different shapes and sizes to suit various
clinical needs.
• 9. Material should withstand sterilization process.
• Source strength specification:
1. Activity: mCi
2. Exposure rate at a specified distance in air: NCRP
recommendation( usually 1 m) exposure at any point proportional to
activity and exposure rate constant.
3. Equivalent mass of Radium: mg- Ra- eq.
Exposure rate constant:
Expressed as numerically equal to the exposure rate in R/h at a point 1 cm from
a 1-mCi point source. (R-cm2/h/mCi).
In the case of radium, the source strength is specified in terms of milligrams of
radium ICRU : for radium filtered by 0.5 mm platinum 8.25 R-cm2/h/mg.
Air Kerma Rate Constant: Si units: mGy-cm2/h/MBq.
4. Air Kerma Strength(AAPM) The air kerma strength is defined as the
product of air kerma rate in “free space” and the square of the distance of
the calibration point from the source center along the perpendicular
bisector(usually 1 m). Unit: μGy-m2/h.
5.Integrated Reference Air Kerma/ Total Reference Air Kerma: summation
of the product of air kerma strength and time for all the sources. Unit :
μGy-m2
TYPES OF BRACHYTHERAPY IMPLANTS
• Intracavitary: Sources are placed into a body cavity.
• Interstitial: Sources are surgically implanted into the target
tissue.
• Surface plaque: Sources are loaded into a plaque which is
brought into contact with a skin/mucosal surface immediately
adjacent to target tissue.
• Intraluminal: Sources are inserted into the body lumen.
• Intraoperative: Sources are brought surgically into or near the
tumor volume.
• Intravascular: Sources are brought intravascularly into a lesion
or near a lesion.
Treatment Duration

• Temporary implant
• Dose is delivered over a period of time that is short in
comparison with the half-life of the sources.
• Sources are removed when the prescribed dose has been
reached.
• Permanent implant
• Dose is delivered over the lifetime of the sources
• The sources undergo complete radioactive decay.
DOSE RATES

• As per Report No. 38 of the ICRU,

• Low dose rate (LDR) -0.4-2Gy/hr
• Medium dose rate (MDR) - 2-12 Gy/hr
• High dose rate (HDR) - >12Gy/hr
• Ultra low dose rate: 0.01-0.3 Gy/hr
BRACHYTHERAPY DOSIMETRY

• Dosimetric systems are set of rules, specific to a radioisotope

and its spatial distribution in the applicator to deliver a
defined dose to a designated region
• Within any system, specification of treatment in terms of
dose, timing, and administration is necessary so as to
implement prescription in a reproducible manner
• Early treatments of Radium - No physical or biological basis,
empirical
• Gradually replaced with Cs-137, Ir-192, Co-60, Au-198, and
I-125 sources
Interstitial Brachytherapy
• Sealed Radioactive sources directly implanted into the tumor in a
geometric fashion
• As radical brachytherapy alone (smaller lesions)
• Local boost in combination with EBRT (larger lesion)
• Easily accessible lesions

• Head & neck tumors

• Ca breast- Boost /PBI
• Ca prostate
• Soft tissue sarcoma
Classical Systems for Interstitial Brachytherapy

• Manchester system (Paterson-parker)

• Quimby system
• Paris system
• Computer system

All interstitial implant systems consist of the following

components:
• Distribution rules
• Dose specification and implant optimization criteria
• Dose calculation aids
The Manchester system
• Developed by Paterson and Parker in the 1930s
• The aim of this system is to deliver a uniform dose throughout
the target volume.
• Sources are distributed at 1 cm seperation, with more source
strength concentrated in the periphery of the target volume.
• Patterson-Parker tables - give cumulative source strength as a
function of:
– Area for planar implants.
– Volume for volume implants.

• The treatment surface is the area bounded by the peripheral

needles, parallel to and 5 mm from the needle plane.
Manchester system
• Planar implants - target /treatment surface -
area bounded by the peripheral needles.

• Full-intensity sources -periphery and partial-

strength needles - central needles.

• Single-plane – 1cm-thick target volume

• Double-plane - >1 cm target volumes using
two parallel planes of needles

• Volume implants - target volume - region

bounded by the peripheral sources.
• 2 groups of sources -“belt” and “core” sources
• Target volumes thicker than 2.5 cm
Manchester System Rules
• Dose and dose rate - 6,000 R to 8,000 R in 6–8 days (1,000 R/day; 40 R/hour)
• Dose specification criterion - Effective minimum dose is 10% above the absolute
minimum dose in treatment plane or volume.
• Dose gradient - Dose in treatment volume or plane varies by no more than ± 10%
from stated dose
• Linear activity -Variable: 0.66 and 0.33 mgRaEq/cm
• Source strength distribution: planar
• Area < 25 cm2 : 2/3 periphery; 1/3 center
• 25 < Area < 100 cm2: 1/2 periphery; 1/2 center
• Area >100 cm2: 1/3 periphery; 2/3 center
• Source strength distribution: volume
• Cylinder: belt : core : end : end = 4:2:1:1
• Sphere: belt : core = 6:2
• Cube: 1/8 of the activity in each face ,2/8 of the activity in the core
• Needles preferebly crossed on both ends
Mean central dose (MCD)
• Mean central dose (MCD)-ICRU report on dose
specification in interstitial BT
• MCD –arithmetic mean of the doses at mid
distance between each pair of adjacent sources for
single plane implant and mean of the local
minimum doses between each group of three
adjacent sources in a multi plane implant.
• All local minimum doses are specified in the
“central transverse” plane, which is normal to and
bisects the source axes
• The maximum dose (110% of stated dose) of the
Manchester system closely approximated by MCD
• Minimum peripheral dose and stated dose are
given by 80% and 89% of MCD.
Quimby system
• Developed by Edith Quimby in the U.S.

• Based on uniform distribution of source strength - equal linear intensity

needles are distributed uniformly (fixed spacing) in each implant.

• The dose in the target centre exceeding the dose on the periphery.

• Allows higher source strength compared to Manchester system .

• Dose value obtained from the Quimby tables represents the minimum dose
within the target volume.

• The Quimby planar and volume dose specification criteria are inconsistent.

• Quimby implants deliver 25-90% more mgRaeq-hr per unit dose than P-P
volume implants of similar size.
Paris system (Pierquin et al)
• Developed in 1966
• Designed for temporary implants of longer line sources- Ir-192 wires.
• Used for single and double plane implants.
• Definition of the target volume: thickness T, length L, and width W.
• The maximum thickness of a target volume treatable is about 2.5 cm.
• Sources are distributed over a predetermined target volume in
accordance with the system rules.
• Sources are placed in parallel rectilinear arrays, centres located in the
central plane.
• Adjacent sources are equidistant :
 Single plane implant : equal spacing
 Double plane implant: groups of sources in equilateral triangles or
squares
Positioning sources

• Number of sources is determined by WxT.

• Sources positioned parallel to length, L in single- and
double-plane implants.
• Linear activity:4-14 μGy-m2/h/cm Ir192 wires
• Source spacing
 Short or long
 Lateral safety margin and spacing is function of
thickness.
• Peripheral needles are implanted along the
margins of CTV, 2-4mm inside the
treatment surface.
• Crossing needles are not used
• AL=1.45xL
Basal dose: average of the minimum doses between
pairs or groups of adjacent sources in the central
transverse plane.

Dose specification criterion -Reference dose

(prescribed dose) - 85% of the BD

Dose gradient Fixed 15% gradient between reference

dose and basal dose.

The “hyperdose sleeve” (region receiving at least

twice the reference dose) diameter should be <8–10
mm

Dose and dose rate - 6,000 cGy to 7,000 cGy in

3–11 days.
PARIS SYSTEM
Computer system
• Advanced treatment planning system.
• Flexibility to deviate .
• Optimize isodose distributions .
• May try to compensate for poor implant geometry.
• Rapid & fast.
• Helps modify implant

• Linear strength of sources is constant spaced uniformly and covering entire

target volume
• T.V.-sufficient safety margins
• Peripheral sources implanted on target boundary
• Dose is specified by isodose surface that just surrounds the target or implant.
• Active length of the line source should be 40% longer than target length.
• Implant is hotter in the centre than in periphery.
Dose Computation

• Dose calculation Formalisms’ (AAPM TG 43 algorithm,

Monte Carlo)
• Sievert Integral
• Pre calculated dose tables: nomograms

• For Radium & other long lived sources: Dose rates in form of
isodose curves used to calculate implant duration.
• For Iridium & relatively short lived implants: Computer
calculates cumulative dose with decay correction
DOSE DISTRIBUTION IN INTERSTITIAL
THERAPY
• Dose distribution -non- homogeneous ,steep dose gradients
and regions of high dose surrounding each source.
• Within the volume of the implant there are regions where
the dose gradient approximates a plateau .
• Here, dose can be calculated most reproducibly and
compared easily.
• Equidistant between adjacent neighboring sources of
identical activity local minimum doses.
• Variations between local minimum doses can be used to
describe the dose uniformity of an implant.
• Computer systems :the three- dimensional dose distribution
as isodose surfaces.
• the central plane of the implant should be chosen for this
purpose.
ICRU Report No. 58

• A description of clinical target volumes.

• The sources, technique and implant time.
• The total reference air kerma.
• A description of the dose: prescription point/surface,
prescription dose, reference doses in the central plane, mean
central dose and peripheral dose.
• A description of the high and low dose region and dose
uniformity indices.
• Dose–volume histograms (DVHs)
INTRACAVITARY BRACHYTHERAPY

• Cancer of the cervix, uterine body and vagina.

• Various applicators are in use to hold sources in an appropriate
configuration in the tumor volume.
• A cervical applicator consists of a central tube (tandem) and
lateral capsules (ovoids or colpostats)

• 1911: Stockholm System – Forsell

• 1919: Paris System - Regaud
• 1934: Manchester System - Paterson & Parker
Stockholm System

• Fractionated (2-3 applications) at 3 weekly intervals delivered

within about a month
• Each application 20-30 hours
• The amount of Radium was unequal in
– uterus -30-90 mg, in linear tube of flexible rubber
– vagina - 60-80 mg, in shielded silver or gold boxes
• Vaginal and uterine applicators were not fixed together
• Total prescribed dose -Total mg-hrs were usually 6500 to
7100 mg-hrs out of which 4500 mg-hrs were in vagina.
• Dose rate of 110R/hr.
Paris System
• Single application of radium for
120 hours.
• Delivers a dose of 7200-8000 mg-
hrs at dose rate of 45R/h
• Almost equal amounts of Radium
were used in uterus and vagina
• Intrauterine tube contained three
sources with source strength ratio
of 1:1:0.5
• Two cork intravaginal cylinders
(colpostats) had one source each of
almost the same strength as the top
intrauterine source.
Classical Manchester System

• Developed by Todd & Meredith in 1930 and pioneered by

Patterson & Parker.
• Modification of Paris and Stockholm systems
– source loading technique of Paris system
– fractionated delivery of dose from the Stockholm system.
 Define treatment in terms of dose to a point representative of
the target, more or less reproducible from patient to patient.
• Specifies the spatial distribution of sources in specially
designed applicators and their relative activity
• Defines reference points -A & B at which dose is calculated
• Abandoned previous dosage system of mg/hrs in favor of
roentgen unit.
Manchester System
• Point A is defined as be 2 cm lateral to the
centre of uterine canal and 2cm superior to the
mucosa of lateral fornix in the plane of the
uterus.

• 2cm superior from the distal end of the lowest

intrauterine source in the cervical canal and
2cm lateral to the centre of tandem.

• Dose at point A – represents dose to tumor.

• Point B is defined 2cm above the external os

and 5 cm lateral to midline.
• Represents dose to the pelvic walls
• Dose at point B – approx 25-30% of the dose at
point A
Manchester System
• Applicators consisted of a rubber tandem(2-4-6 cm) and two
“ovoids” with diameters 2, 2.5, or 3 cm.

• Separated by a rubber spacer in an attempt to keep a constant

separation between the ovoids.
• Gauze packing

• Loading in the uterine tubes was 10+10+15, 10+15, and 20

mg of Ra for long, medium, and short tubes, respectively.

• Ovoids were loaded with 22.5, 20, and 17.5 mg of Ra for

large, medium, and small ovoids, respectively.

• Standard insertion times were calculated for fixed applicator

configurations .
• Dose limiting structures: bladder, rectum,vaginal mucosa,
rectovaginal septum
Amount of radium was defined in terms of units
1unit=2.5 mg of radium filtered by 1mm platinum
• Design applicators and their loading to enable the same dose-rate to point ‘A’
regardless of combination of applicators used.

• Vaginal contribution to Point A was limited to 40%(1/3rd) of the total dose.

• Standard or ideal loading is 60-40: 60% dose to point A by intrauterine source

and 40% by ovoids.

• The prescribed dose to Point A was 8000 R, delivered in 2 applications 72

hours each with approximately a total application time of 144 h, in the absence
of any external beam.

• Point A dose rate was approx 55.5R/hr for all allowed applicator loadings –
ideal insertion.

• Rectal dose should be 80% or less of the Point A dose

• Largest possible ovoids

• Longest possible tandem

• Mucosal, bladder and rectal

tolerance has to be respected.

• Optimal placement “Pear-

Shaped” distribution .
ICRU Report No. 38 - Intracavitary treatments

• Recommends a common terminology for prescribing, recording and

reporting I/C Brachytherapy applications.

• Recommends a system of dose specification that relates dose

distribution to the target volume( not a specific point).

• Dose is prescribed as the value of an isodose surface that just

surrounds the target volume.

• ICRU reports:
1.A description of the technique .
2.The total reference air kerma (TRAK).
3.The time dose pattern .
4.A description of the reference volume .
5.Absorbed dose at reference points (bladder, rectum, lymphatic
trapezoid, pelvic wall).
Description of the technique:
 Orthogonal radiographs of application
 Source shape, size, filtration
 Applicator type
 Loading pattern
 Applicator geometry-curvature, shielding
material.
Reference volume:
 Recommends reference volume to be taken
as the 60 Gy isodose surface, resulting from
addition of dose contribution from any
EBRT and IC insertions

 It requires to specify the dimensions of the

pear-shaped 60 Gy isodose reference
volume.

 the height , width and thickness of

reference volume can be measured from
radiographs.
Stepping Source Dosimetry Systems (SSDS)
• Uses the same rules for implantation as the Paris System, except
that the active lengths in the catheters remain within the target
surface, even at the longitudinal ends
• Dose points are placed midway between the catheters over the
whole length of the implant.
• Applies polynomial optimization on volume to obtain the same
dose in these dose points
• Originally, prescription dose - 85% of the mean dose in the dose
points.
• Prescription dose is best defined as 90% of the mean dose in the
dose points.
The SSDS Implantation Rules

• Single or double plane implant depends on thickness of target

volume.
• Catheter spacing depends on length of target volume and thickness
of target volume.
• Safety margin is a function of catheter spacing.
• The dwell position spacing = 5 mm.
• The first and the last dose point of each row midway between the
catheters are usually discarded.
• Dwell time is a function of prescribed dose, geometry of the
application and source strength on the day of application.
THANK YOU