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 Outline
 Introduction

 Technical

 Dose calculations

 Clinical
Introduction
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istory

 Discovered in 1898, radium was most common

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

 Xþrays discovered before radium  radium

used for treatment first

 ÷lexander Graham Bell 1903

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

 Usually outþpatient no hospitalization


ighly conformal dose distribution and good
healthy tissue sparing

 Since source is implanted less concern for

localization and target motion

 Very high local doses

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Types of Brachytherapy
 $ =



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

, in which sources are
placed in a lumen.
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, in which sources are
implanted into the target tissue during surgery.
 $ =
  

, in which a single source
is placed into small or large arteries.
 Types of Brachytherapy
 Interstitial
‡ Surgical placement of sources within the tissue

‡ Temporary or permanent

‡ Most common application for permanent

implant of prostate cancer

‡ Other sites include: some gynecological

tumours, breast tumours and head and neck
  
 

Interstitial brachytherapy can be either


 or
  
.


  
 

Most widely used radionuclide at the present time is iridiumþ192

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The relatively short halfþlife of iridiumþ192 (70 days) means

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

Iridiumþ192 has two advantages:

1) The source size can be small, and

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

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

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jncapsulated sources with relatively short halfþlife can be

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

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

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

Iodineþ125 has been used most widely to date for permanent

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

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

‡ Intracavitary treatments are always temporary

‡ Most common implant worldwide

‡ Most gynecological tumours of the uterine cavity and

vagina

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

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

‡ Molds placed on surface of target to treat

superficial tissue

‡ Less commonly used

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

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

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

‡ Distribution of sources cannot change after implant

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

lives (~days)

‡ 125I, 198÷u and 103Pd

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

‡ Better control of dose distribution

‡ Usually fractionated

‡ Can alter insertion in subsequent fractions

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

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

  
  
  
 
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 Containing the radioactivity;

 Providing source rigidity;

 ÷bsorbing any j and, for photon emitting sources,

radiation produced through the source decay.
 Sources
 ÷lthough 226Ra was original brachytherapy source 
not ideal
 Characteristics
‡ jnergy of þray (shielding)
‡
alf life
‡ Toxicity
‡ Machinability
‡ Specific activity
‡ Source strength;
‡ Inverse square fallþoff of dose with distance from the
source
 Brachytherapy sources
  
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 192Iridium

 Complicated þray spectrum with average energy ~

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

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

  
, the
distance between the actual
ends of the source;



 

 , (mg radium
content); and
 (d) 

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

 Wire mechanically drive out of afterloader through

one of 20 channels

 Program range of treatment positions and dwell

times

 Typically 0.5 cm step sizes (up to 20 steps)

 Stepping of source

147 cm 150 cm

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


`
 
(SK)

 Relating the two

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

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

±
ard to measure output, used to calibrate sources
‡ 

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

 Used to calibrate well type ionization chamber

 These are used for routine calibration

 Recalibrated every two years at accredited dose lab

 Specific to isotope of interest

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

(b) ÷ttenuation in tissue  þë

(c) Scatter in tissue

(1) Point Source:

+ ,÷- ()* þë .

 Task Group þ43
 Modular method of dose calculation using tabular
data as a function of position
m{
 m m { 

m{ m

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

 For 192Ir, anisotropy less significant

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

(m )
 (m ) 0

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

Tip of marker seed #7

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

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

Seed #7
cervical os

Rectal retractor
 Uterine Cervix

Foley
catheter

ODose to bladder and rectum

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

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

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