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Principles and Practice

of Brachytherapy
using afterloading systems
Edited by

C.A. Joslin
Emeritus Professor of Radiotherapy, Leeds University,
Tunbridge Building, Regional Cancer Treatment
Centre, Cookridge Hospital, Leeds, UK

A. Flynn
Head of Brachytherapy Physics, Department of
Medical Physics and Engineering, Cookridge Hospital,
Leeds, UK

and

E.J. Hall
Professor of Biophysics, Radiology and Radiation
Oncology, Director-Center for Radiological Research,
Department of Radiation Oncology, Columbia
University, New York, USA

A member of the Hodder Headline Group


LONDON
Co-published in the United States of America by
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First published in Great Britain in 2001 by
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Contents

Contributors v

Preface viii

PART I THE PHYSICS OF BRACHYTHERAPY 1

1 Sources in brachytherapy Edwin Aird 3

2 Source specification and dosimetry J.M.Wilkinson 11

3 Calibration of sources Colin H.Jones 19

4 Systems of dosimetry Anne Welsh and Karen D'Amico 35

5 Computers in brachytherapy dosimetry Robert van der Laarse and Robert W. Luthmann 49

6 Dose specification and reporting: the ICRU recommendations Andre Wambersie and Jan J. Battermann 81

7 Afterloading systems A. Flynn 103

8 Quality assurance in low dose-rate afterloading Eric D. Slessinger 112

9 Quality assurance in high dose-rate afterloading Colin H. Jones 133

10 Radiation protection in brachytherapy A.M. Bidmead 147

PART II THE RADIOBIOLOGY OF BRACHYTHERAPY 159

11 The radiobiology of low dose-rate and fractionated irradiation Joel S. Bedford 161

12 Dose-rate effects with human cells G. Gordon Steel and John H. Peacock 180

13 Radiobiology of high dose-rate, low dose-rate, and pulsed dose-rate brachytherapy


David J. Brenner, Roger Dale, Colin Orton, and Jack Fowler 189

14 Predictive assays for radiation oncology John A. Cook and James B. Mitchell 205

15 Principles of the dose-rate effect derived from clinical data Eric J. Hall and David J. Brenner 215

PART III CLINICAL PRACTICE 223

16 Endobronchial brachytherapy in the treatment of lung cancer Burton L Speiser 225

17 Brachytherapy in cancer of the esophagus A.D. Flores 243

18 High dose-rate afterloading brachytherapy for prostate cancer P.J. Hoskin 257

19 Low dose-rate brachytherapy for breast cancer Julia R. White and J. Frank Wilson 266

20 Brachytherapy in the treatment of head and neck cancer A. Gerbaulet and M. Maher 284
iv Contents

21 High dose-rate interstitial and endocavitary brachytherapy in cancer of the head and neck
Peter Levendag, Connie de Pan, Dick Sipkema, Andries Visser, Inger-Karine Kolkman, and Peter Jansen 296

22 Brachytherapy in the treatment of pancreas and bile duct cancer Dattatreyudu Nori, Suhrid Parikh,
Srinath Sundararaman, and Margot Heffernan 317

23 Brachytherapy for treating endometrial cancer H.A. Ladner, A. Pfleiderer, S. Ladner, and U. Karck 333

24 Low dose-rate brachytherapy for treating cervix cancer: changing dose rate R.D. Hunter and S.E. Davidson 343

25 High dose-rate brachytherapy for treating cervix cancer C.A Joslin 354

26 Brachytherapy for brain tumors Maarten C.C.M. Hulshof and Jan J. Battermann 373

27 Interstitial brachytherapy in the treatment of carcinoma of the cervix A.M. Nisar Syed and
Ajmel A. Puthawala 379

28 Interstitial brachytherapy in the treatment of carcinoma of the anorectum Ajmel A. Puthawala and
A.M. Nisar Syed 387

29 High dose-rate brachytherapy in the treatment of skin tumors C.A. Joslin and A. Flynn 393

30 Hyperthermia and brachytherapy Peter M. Corry, Elwood P. Armour, David B. Gersten,


Michael J. Borrelli, and Alvaro Martinez 400

31 The costs of brachytherapy Graham Read 410

32 Quality management: clinical aspects C.A. Joslin 423

33 Safe practice and prevention of accidents in afterloading brachytherapy A. Flynn, S.E. Griffiths, and
C.A. Joslin 433

34 Pulsed low dose-rate brachytherapy in clinical practice Patrick S. Swift 443

Index 451
Contributors

Edwin Aird S.E. Davidson


Medical Physics Department, Mount Vernon Hospital, The Christie Hospital NHS Trust, Manchester, UK
Middlesex, UK
Connie de Pan
Elwood P. Armour Department of Radiation Oncology, Dr Daniel den Hoed
Department of Radiation Oncology, William Beaumont Cancer Centre, Rotterdam, The Netherlands
Hospital, Michigan, USA
A.D. Flores
Jan J. Battermann 7955 E, Chaparral Unit 125, Scottsdale, Arizona 85250, USA
Department of Radiation Oncology, Academisch Ziekenuis
Utrecht, The Netherlands A. Flynn
Medical Physics Department, Cookridge Hospital, Leeds, UK
Joel S. Bedford
Department of Radiological Health Sciences, Colorado State Jack Fowler
University, Colorado, USA Department of Human Oncology K4/336, University of
Wisconsin Cancer Center, Wisconsin, USA
A.M. Bidmead
Physics Department, Royal Marsden NHS Trust Hospital, A. Gerbaulet
London, UK Brachytherapy Department, Institut Gustave-Roussy, Villejuif,
France
Michael J. Borrelli
Department of Radiation Oncology, William Beaumont David B. Gersten
Hospital, Michigan, USA Department of Radiation Oncology, William Beaumont
Hospital, Michigan, USA
David J. Brenner
Center for Radiological Research, Columbia University, New S.E. Griffiths
York, USA Department of Radiotherapy, Regional Cancer Treatment
Centre, Cookridge Hospital, Leeds, UK
John A. Cook
Radiation Biology Branch, National Cancer Institute, National Eric J. Hall
Institutes of Health, Maryland, USA College of Physicians and Surgeons Center for Radiological
Research, Columbia University, New York, USA
Peter M. Corry
Department of Radiation Oncology, William Beaumont Margot Heffernan
Hospital, Michigan, USA Tumor Registry, New York Hospital Medical Center of Queens,
New York, USA
Roger Dale
District Department of Medical Physics, Charing Cross P.J. Hoskin
Hospital, London, UK Marie Curie Research Wing, Mount Vernon Hospital,
Middlesex, UK
Karen D'Amico
Medical Physics Department, Cheltenham General Hospital, Maarten C.C.M. Hulshof
Cheltenham, UK Academisch Medisch Centrum, Amsterdam, The Netherlands
vi Contributors

R.D. Hunter Suhrid Parikh


The Christie Hospital NHS Trust, Manchester, UK Radiation Oncology, New York Hospital Medical Center -
Cornell, New York, USA and New York Hospital Medical Center
Peter Jansen of Queens, New York, USA
Department of Radiation Oncology, Dr Daniel den Hoed
Cancer Centre, Rotterdam, The Netherlands John H. Peacock
Radiotherapy Research Unit, Institute of Cancer Research,
Colin H. Jones Surrey, UK

Physics Department, Royal Marsden NHS Trust, London, UK


A. Pfleiderer
University Hospital for Women, Freiburg, Germany
C.A. Joslin
Leeds University, Department of Radiotherapy, Regional
Ajmel A. Puthawala
Cancer Treatment Centre, Cookridge Hospital, Leeds, UK
Department of Radiation Oncology, Long Beach Memorial
Medical Center, California, USA
U. Karck
University Hospital for Women, Freiburg, Germany
Graham Read
Oncology Services, Royal Preston Hospital, Preston, UK
Inger-Karine Kolkman
Department of Radiation Oncology, Dr Daniel den Hoed Dick Sipkema
Cancer Centre, Rotterdam, The Netherlands Department of Radiation Oncology, Dr Daniel den Hoed
Cancer Centre, Rotterdam, The Netherlands
H.A.Ladner
University Hospital for Women, Freiburg, Germany Eric D. Slessinger
Regional Cancer Center, Community Hospital Indianapolis,
S. Ladner Indiana, USA
University Hospital for Women, Freiburg, Germany
Burton L Speiser
Peter Levendag St Joseph's Hospital and Medical Center, Department of
Department of Radiation Oncology, Dr Daniel den Hoed Radiation Oncology, Arizona, USA
Cancer Centre, Rotterdam, The Netherlands
G. Gordon Steel
Radiotherapy Research Unit, Institute of Cancer Research,
Robert W. Luthmann
Surrey, UK
St Vincent's Medical Center, Department of Radiation
Oncology, Florida, USA
Srinath Sundararaman
Radiation Oncology, New York Hospital Medical Center of
M. Maher
Queens, New York, USA
Radiotherapy Department, Mater Private Hospital, Dublin,
Ireland
Patrick S. Swift
Radiation Oncology, Alta Bates Comprehensive Cancer Center,
Alvaro Martinez
California, USA
Department of Radiation Oncology, William Beaumont
Hospital, Michigan, USA A.M. Nisar Syed
Department of Radiation Oncology, Long Beach Memorial
James B. Mitchell Medical Center, California, USA
Radiation Biology Branch, National Cancer Institute, National
Institutes of Health, Maryland, USA Robert van der Laarse
Nucletron BV, Veenendaal, The Netherlands
Dattatreyudu Nori
Radiation Oncology, New York Hospital Medical Center - Andries Visser
Cornell, New York, USA and New York Hospital Medical Center Department of Radiation Oncology, Dr Daniel den Hoed
of Queens, New York, USA Cancer Centre, Rotterdam, The Netherlands

Colin Orton Andre Wambersie


Gershenson Radiation Oncology Center, Harper Hospital and Unite de Radiobiologie et de Radioprotection, Faculte de
Wayne State University, Michigan, USA Medecine, Universite Catholiquede Louvain, Bruxelles, Belgium
Contributors vii

Anne Welsh J.M. Wilkinson


Medical Physics Department, Cheltenham General Hospital, North Western Medical Physics, Christie Hospital, Manchester,
Cheltenham, UK UK

Julia R. White J. Frank Wilson


Medical College of Wisconsin, Wisconsin, USA Medical College of Wisconsin, Wisconsin, USA
Preface

Brachytherapy was for many years in a state of decline, of clinical experience, an understanding of the principles
principally because of the radiation hazards to users and of radiobiology and physics is of great importance. It is
those associated with the management of patients. The also prudent that clinical radiation oncologists continue
introduction of afterloading machines in the 1960s pro- to update their state of knowledge with respect to cur-
vided the means to control the movement and position of rent practice.
individual radioactive sources and greatly reduced the The purpose of this book is not only to present to the
radiation exposure to staff. As a result, brachytherapy trainee clinical oncologist the scientific background and
underwent a renaissance and provided the necessary stim- principles of brachytherapy afterloading techniques, but
ulus to promote the development of afterloading also to update those who specialize in brachytherapy.
brachytherapy techniques. These developments have been The book is presented in three sections: physics, radiobi-
further supported by the availability of nuclides, particu- ology, and clinical treatment. The sections attempt to
larly cobalt-60, cesium-137, and iridium-192 and, more cover the scientific principles, technical procedures, and
recently, radioactive seeds of iodine-125 and palladium - clinical applications of'afterloaded' brachytherapy.
105. In parallel with the technological advances in after- The editors have aimed at a consistent presentation
loading machines, there have been major developments in for the various chapters without attempting to interfere
imaging techniques and computerized planning. with the different styles of the individual authors. Some
Cancer management generally has undergone major chapters will be found to be more extensive than others,
advances since the 1960s and brachytherapy has played which is mainly a reflection of the widespread applica-
an increasingly important role. The optimal manage- tion of brachytherapy techniques within the subject of
ment of cancer patients requires expert teams who spe- those chapters.
cialize in certain cancer sites within which brachytherapy We hope that readers of this textbook will find the
may have a specific place. Much of this work is now contents helpful in their work.
being provided on an outpatient or day-care basis and The editors would like to express their appreciation to
prolonged hospital stay is proving to be unnecessary. all authors for their well-prepared manuscripts and for
Clinical training is largely obtained by observation of their tolerance during the book's production.
and training from one's peers and also from supervised
hands-on experience. In parallel with the development C.A. Joslin, A. Flynn, and Eric J. Hall
PART
I
The physics of brachytherapy

1 Sources in brachytherapy 3
2 Source specification and dosimetry 11
3 Calibration of sources 19
4 Systems of dosimetry 35
5 Computers in brachytherapy dosimetry 49
6 Dose specification and reporting: the ICRU
recommendations 81
7 Afterloading systems 103
8 Quality assurance in low dose-rate afterloading 112
9 Quality assurance in high dose-rate afterloading 133
10 Radiation protection in brachytherapy 147
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1
Sources in brachytherapy

EDWIN AIRD

1.1 INTRODUCTION The gamma radiation from a radium source is of


higher energy than is necessary for brachytherapy.
Radiation protection for these sources requires large
1.1.1 Radium thicknesses of lead, which can cause problems when it
comes to:
Radium was discovered by Marie Curie in 1898. Within transporting sources in heavy containers
3 years of this discovery the first patients were treated using very heavy protective screens around the
with radium implanted into their tumors. patient
In the UK, St Bartholomew's Hospital received its first the need for a heavy rectal shield in applicators used
radium for clinical use in 1906. Early clinical experience for gynecological treatment.
with these sources led to radiation necrosis and it The practical maximum activity concentration (the
became clear that this was due, in part, to the intense specific activity) of radium salt is low (approximately
beta-ray dose from the radium. It was not until 1920 that 50 MBq mm~3 of active volume). Sources of higher
successful filtration of the beta-rays was achieved. activity are therefore bulky and not suitable for
Radium was then used extensively throughout the afterloading systems.
world. Physicists in the major clinical centers developed
dosimetry systems for interstitial and intracavity
brachytherapy. The Manchester and Paris systems are 1.1.2 Radium substitutes
probably still the most widely used for interstitial ther-
apy. However, in general radium has been replaced by This was the phrase used to describe the first set of new
other radionuclides because, although it has a long half- (artificial) radionuclides which were found useful for
life, it has several disadvantages: brachytherapy from about 1950 onwards, though it is only
very recently that most radiotherapy centers have stopped
Radium and several of its daughter products, using radium. It was found that there were very few
including radon, are alpha emitters. Radon is a noble radionuclides with the appropriate properties of the ideal
gas which is soluble in tissue. This gas could escape brachytherapy source. These properties are as follows:
through a hairline crack - not easily detected by a
visual check - in the radium capsule. If an implanted (A full discussion of these points may be found in the
radium source were to be ruptured within the British Journal of Radiology Supplement 21 (1987); an
patient's body, radium and its daughter products may abbreviated set is stated here.)
become deposited more or less permanently in the Photon energy should be low to medium (0.03-0.5
bone. MeV) to minimize radiation protection problems
There is also the possibility of damage - by (with the proviso that low-energy radionuclides
incineration or mechanical means - when the sources should not be used near bone because of the
are lost or while they are being processed, with the enhanced dose to bone at these energies).
subsequent release of toxic radioactivity to the For permanent stock, a long half-life is desirable such
environment. that the radioactive decay within the practical lifetime
4 Sources in brachytherapy

of the source and its container (typically 10 years) is stable isotope and limits the specific activity possible.
small. However, for iodine-125, the reaction proceeds in two
For permanent implantation, a fairly short half-life is stages, with xenon as the initial target element:
essential in order to minimize the time over which
special precautions, towards relatives of a radioactive
patient and members of the public, need to be in
place. The radioactive xenon decays by beta emission, with a
The nuclide should be available at high specific half-life of 8 days, to the required125/53I,which can then be
activity. chemically extracted as a pure radioisotope.
There should be no gaseous disintegration product. To estimate the yield of a given radionuclude, it is pos-
The nuclide should be available in a form which does sible to use the simple form (for short irradiation time
not powder or otherwise disperse if the source is and low fluxes) of the yield equation given in The
damaged or incinerated. Radiochemical Manual [ 1 ]:

The first sources to be used as alternatives to radium


were cobalt-60, gold-198, cesium-137 and iridium-192.
These are all described briefly below. The most com- where s is the reaction cross-section; (j is the neutron
monly used sources at this time are cesium-137 and flux; n0 is number of atoms in target (=N 0 wq/A, where w
iridium-192, both of which are used in after-loading is target mass, q is the isotopic abundance of the nuclide
systems. Iridium-192 has the possibility of high specific of interest in the target element, and A is the atomic mass
activity, which allows it to be used as a high dose-rate of the target element, N0 = Avogadro's number); t =
(HDR) source. bombardment time; l = decay constant of the product
element.
The specific activity, S, of the target nuclide may be
1.1.3 New sources approximated to:

The newer sources are not known as radium substitutes,


mainly because they have very different properties from
radium, namely very much higher specific activity (for
For long irradiation times:
example the HDR iridium-192 source) and very differ-
ent energy. The only new source that has been accepted
into routine clinical use in certain centers throughout
the world is iodine-125. Palladium-103 is also now avail-
and S Ssat, the maximum activity possible for a given
able as a standard commercial source.
neutron flux.
The other sources that are still at the research stage of
Example. For indium-191, the neutron capture cross-
development, to find out whether they can be of use clin-
section is 910 barns. (This is very high, compared with
ically, are samarium-145, americium-241, and ytter-
cobalt-60, for example, which has a cross-section of 43
bium-169.
barns.) If the neutron flux is high (typically 1013 rt.cm-2S-1),
using the above equations, it is possible to show that the
maximum theoretical specific activity for iridium-192 is
1.2 PRODUCTION OF RADIONUCLIDES about 29 TBq g-1, which equates to about 2.5 TBq for an
HDR source of 0.086 g.
In practice, although the neutron flux is probably
The most common method of producing the radio-
higher:
nuclides used in brachytherapy, apart from cesium-137
(which is a fission product), is by neutron bombardment
in a nuclear reactor. The reaction is that of neutron cap-
ture, normally in the stable isotope of the element The irradiation times are shorter, so that only a fraction
required (except for iodine-125, see below). Thus, for of Ssat is reached. The typical specific activity produced
iridum the reaction is: for HDR sources is 4.3 TBq g-1 (for a 370 GBq source).
It is interesting to compare the specific activities (in
terms of activity per unit length) available for the differ-
For cobalt-60 the reaction is: ent radionuclides used now in brachytherapy with those
in the older sources.
Iridium wire 37 MBq mm-1
This method of production has the disadvantage that Iridium HDR source 74 GBq mm-1 actual source
the radioactive isotope cannot be separated from the length
Brachytherapy sources used in afterloading systems 5

Cesium miniature 333 MBq mm -1 actual Table 1.2 Examples of source trains suitable for Manchester
cylindrical source length (for manual System
afterloading source
trains)
Cobalt-60 beads 592 MBq mm-1 actual
source length (in a set of
active beads) Medium vaginal ovoid 3 1.7 127
Compared with radium 50 mg in 13.5 mm active Medium intrauterine 5 2.1 158
length, 20 mm actual Medium tandem 11 5.4 412
length, equates to 92.5 a
The nominal output is expressed in terms of air kerma rate (AKR) at
MBq mnT-1 actual length 1 m from the center of the source.

13 BRACHYTHERAPY SOURCES USED IN


AFTERLOADING SYSTEMS

Except where otherwise stated, reference data concerning


sources come from the Amersham Catalogue of Radiation Image Not Available
Source for Oncology.

13.1 Cesium-137 (Table 1.1)

FORMS FOR MANUAL AFTERLOADING


Miniature cylindrical sources (Figure 1.1) contain
cesium-137 glass beads encapsulated in stainless steel. Figure 1.1 Cylindrical cesium-137 sources as used in the
They are used in source trains in machine and manual Amersham afterloading source train. (Reproduced by kind
afterloading systems for gynecological brachytherapy. permission of Nycomed Amersham plc.)

AMERSHAM MANUAL AFTERLOADING SYSTEM


In the Amersham Manual Afterloading System (Figure
1.2) a source train consists of a flexible stainless-steel
holder containing miniature cylindrical sources sepa-
rated by spherical steel spacers 1.8 mm in diameter. The

Table 1,1 Properties of cesium-137


Production A fission product
Small quantities (less than 1%
cesium-134 present [2], which
decays with a half-life of about 2 Image Not Available
years)
Half-life 30.17 years
Decay scheme
Beta energies Emission probability-betas*
0.512 MeV 94.6%
1.173MeV 5.4%
Photon energies Emission probability - photons
0.662 MeV 90.1%
Barium X-rays
0.032-0.038 MeV -7%
Beta filtration 0.5 mm of platinum or stainless
steel
Figure 1.2 Source train used in the Amersham afterloading
Half value layer in lead 6.5mm
system. (Reproduced by kind permission of Nycomed Amersham
* Data from The Radiochemical Manual [1]. Pic.)
6 Sources in brachytherapy

sources and spacers are retained in the holder by a steel CESIUM-137 SOURCES FOR BUCKLER* AFTERLOADING
spring, secured by a screwed-in end plug. They are These are cylindrical sources used in the fixed ovoids of
designed to locate in the Amersham manual afterloading the Buchler Gynaecological System. The sources vary
plastic applicators. The standard set of 11 source trains is from 10.1 GBq with active dimensions 2 mm x 3.5 mm
suitable for the Manchester System of Gynecological to fit applicators 6 mm diameter for low dose rates
tube dosage. Some examples are given in Table 1.2. (LDRs), to 148 GBq with active dimensions 4.1 mm x
11.5 mm to fit applicators 8 mm diameter for HDRs.
WALSTAM-TYPE SOURCES [3]
CESIUM-137 SOURCES FOR CURIETRON
These are short, cylindrical sources with hemispherical These are cylindrical sources that are very similar to
ends. They consist of cesium-137 in a ceramic matrix con- those of the Amersham Manual Afterloading System, but
tained in a welded stainless-steel capsule. They are used in for use in a remote afterloading system in which the
dome or cylindrical gynecological applicators. The sources source trains are attached to a cable drive.
approximate a point source of activity higher than that
used in the Amersham (Manchester) System (Table 1.3).
1.3,2 Cobalt-60 (Table 1.4)
Table 1.3 Waktnm-tvnr snurrtx;
FORM OF SOURCE

Although used in various forms in the past, the most


common form in recent years is in 'bead' form, with a
0.37-74 GBq 28.5-570.0 mGy h-1
design very similar to that used for cesium-137 beads in
the Selectron unit. However, the activity of cobalt-60
beads is higher and they are used for HDR brachy-
therapy.
REMOTE AFTERLOADING CESIUM-137 SOURCES

Spherical Sources
Spherical sources are used in the Selectron (Nucletron
BV) afterloading system (Figure 1.3). The cesium-137 is Table 1.4 Properties of cobalt-60
incorporated into a glass bead and encapsulated in stain-
Production By neutron activation of the stable
less-steel ball bearings (referred to as 'beads' or 'pellets')
isotope cobalt-59
which, together with inactive spacer beads, can be pneu-
matically loaded from the intermediate safe into a Half-life 5.27 years

patient applicator along a plastic tube (nominal activity Decay scheme


1.48 GBq per bead, air kerma rate 112mGyh-1m2). Beta energies Emission probability - beta
0.318 MeV 99.9%
Photon energies Emission probability - photon
1.17 MeV 99.9%
1.33 MeV 100.0%*
Beta filtration Typical source wall thickness
Half value layer in lead 10mm

* Data from The Radiochemical Manual [1].

Image Not Available


133 lridium-192 (Table 1.5)

FORMS OF IRIDIUM-192
Wire
In Europe, platinum-covered iridium-192 wire is sup-
plied in 500 mm length coils. The wire consists of an
active iridio-platinum core, 0.1 mm thick, encased in a
sheath of platinum, 0.1 mm thick.

Figure 1.3 Spherical cesium-137 source as used in the Selectron


afterloading system. (Reproduced by kind permission of
Nucletron BV.) * Buchler GmbH, Braunschweig, Germany.
Brachytherapy sources used in afterloading systems 7

Table 1.5 Properties of iridium-192

Production By neutron activation of the stable isotope iridium-191; the process also produces quantities of
iridium-194 (from the activation of iridium-193); because this has a half-life of only 17 h, it
does not contribute a significant dose by the time the source is used in the patient
Half-life 73.83 days
Decay scheme
Beta energies Emission probability-betas
0.079-0.672 MeV 0.1-48.1%
Photon energies Emission probability-photons Effective photon energy
Range 0.2-1.06 MeV 0.37 MeV (unencapsulated)
0.4 MeV (encapsulated)
Significant photon energies (>10%) for those greater than 10%
0.296 MeV 28.7%
0.308 MeV 29.8%
0.316 MeV 83.0%
0.468 MeV 47.7%
Beta filtration 0.1 mm platinum
Half value layer in lead 4.5mm

Data from The Radiochemical Manual [1].

Iridium-192 wire is not classified as a 'sealed radiation Wire is cut to the required lengths and loaded into
source.' Because it is activated by neutron irradiation, its plastic tubes or hypodermic needles.
cladding remains slightly active. This is not significant in
its clinical use. For radiation protection purposes, irid-
ium wire is know as a 'closed radiation source.'
Available source strength is shown in Table 1.6. Hairpins (Figure 1.4)
Platinum-covered iridium wire is supplied in the form of
Table 1.6 Available source strength of indium wire 'hairpin' or 'single-pin' shapes. The wire has a diameter
of 0.6 mm to give it added strength; the beta filtration
remains at 0.1 mm platinum. Hairpins are 131 mm over-
all length, with leg length 60 mm nominally (the legs can
1.11-37.00 MBqmnr 126 nGy h-1 mm-1-4.19 mGy h-1
mm-1
be cut to the required length) and with a range of source
strength (Table 1.7).

Image Not Available

Figure 1.4 Platinum-covered iridium-192 wire hairpin (a) and slotted hairpin guide needles (b) as supplied by Nycomed Amersham
pic. (Reproduced by kind permission of Nycomed Amersham plc.)
8 Sources in brachytherapy

Table 1.7 Available source strength of iridium hairpins 13.4 lodine-125(Table1.8[5])


FORMS OF SEED (Figure 1.6a, b)
1.48-11.10 MBq mm-1 168-1257 m G y - 1 mm-1
Type 6711 seeds (Nycomed Amersham plc, Amersham,
UK) are used for permanent implant. Each seed consists
Single pins are 73 mm overall length with a nominal of a welded titanium capsule containing iodine-125
leg length of 60 mm and with a range of source strength adsorbed onto a silver rod (which also acts as X-ray
the same as the hairpins. marker). The active length is 3.0mm and diameter
Slotted stainless-steel guides are used for implanting 0.5mm. The overall length is 4.5mm and diameter
hairpins and single pins. 0.8 mm. Sources are available with air kerma rates at 1 m
of 0.13-7.58 [mGyh-1.
lridium-192 'seeds'
The seeds are used with special applicators to intro-
In the USA these are used instead of wire. Two seed styles
duce them into the patient a fixed distance apart. A new
are commercially available:
type of absorbable suture called Rapid Strand (Figure
1. 0.1 mm diameter core of active wire (30% iridium, 1.7), from Nycomed Amersham plc, has become avail-
70% platinum) surrounded by 0.2 mm cladding of able that encases ten seeds at a fixed distance apart
stainless steel (Best Industries, Springfield, VA). (1cm) in tissue until the suture dissolves (5mm or
2. 0.3 mm diameter core (10% iridium, 90% platinum) 15 mm is also available in this form). The suture mater-
surrounded by 0.1 mm cladding of platinum ial is braided Vicryl which is stiffened thermally and ster-
(Alpha-Omega, Bellflower, CA). ilized by ethylene oxide gas. It eventually dissolves in
tissue. These seeds also emit silver characteristic X-rays
Both seeds are 3 mm active length and are supplied
inside strands of nylon of 0.8 mm outside diameter.
Normal spacing is 1 cm, but other spacings are available. Table 1.8 Properties of iodine-125
Maximum overall length is about 18 cm.
Air kerma strengths range from 120 to 650 MBq per Production Neutron activation of xenon-124
seed. to xenon-125, which then
decays to iodine-125
Miniature iridium-192 sources for high dose rate
Half-life 59.4 days
There is a variety of types of these sources, ranging from
0.2 to 1.3 mm diameter and 1 to 20 mm active length, Decay scheme Iodine-125 decays by electron
capture to the first excited state
with typically up to 370 GBq activity (air kerma rate
of tellurium-125, which
42 mGy h-1).
undergoes internal conversion
Figure 1.5 shows the HDR sources in use throughout 93% of the time; the other 7% is
the world at the present time. They are always perma- occupied by the production of a
nently attached to a cable drive. gamma ray photon of 35.5 keV.
The active wire is encased in stainless steel. There is The electron capture and internal conversion processes give
now a 'new design source' for the Nucletron BV rise to characteristic X-rays as follows:
microSelectron-HDR machine [4] with slightly smaller
(X-ray) Photon energy Decay photons emitted
dimensions (4.95 mm length, 0.90 mm diameter) and 27.4 keV 15%
similar dose distribution, except for some improvement 31.4keV 25%
near the source tip and in the shadow of the cable
Tenth value layer in lead 0.01 mm
assembly.

Image Not Available

Figure 1.5 MicroSelection iridium-192 HDR sources. (Reproduced by kind permission of Nucletron BV)
Brachytherapy sources used in afterloading systems 9

Image Not Available Image Not Available

Figure 1.6 (a) Type 6777 iodine-125 seed, (b) Type 6702 iodine-
Figure 1.7 Rapid Strand. (Courtesy Nycomed Amersham plc.)
125 seed. (Reproduced by kind permission of Nycomed
Amersham plc.)

of 22.1 and 25.5 keV. The average photon energy is taken


to be 27.4 keV.
Type 6702 seeds are used for temporary interstitial
implants. These consist of a welded titanium capsule
containing three resin spheres onto which the iodine- 13.5 Palladium-103 sources (Table 1.9)
125 is adsorbed by an ion exchange.
Sources are available with air kerma rates at 1 m of FORMS OF SEEDS
6.4-51.9 (mGyh-1. The effective energy of the photons The active material is coated onto two graphite pellets
from this seed is taken to be 28.5 keV. 0.9 mm long and 0.6 mm in diameter. Between these is a
A further type of iodine-125 seed is available in North 1 mm long lead marker for radiography. These seeds are
America from Best Industries. The Model 2300 contains encapsulated in a 0.05 mm thick titanium tube, laser
radioactive iodine adsorbed on a tungsten wire that is welded, that is 4.5 mm long and 0.8 mm diameter (the
encapsulated by two walls of titanium. This source offers same dimension as the iodine-125 seed).
the following advantages:
Because it contains radioactive iodine on the ends as
well as on the surface of the tungsten, it produces a Table 1.9 Properties of palladium-103 sources ,
more isostropic dose distribution than the other
Production Palladium-103 is formed when
sources [6].
stable palladium-102 absorbs a
It is available in a wide range of source strengths and
neutron
therefore suitable for both temporary and
Half-life 16.97 days
permanent implantation.
The tungsten wire acts as a radiographic marker. Decay scheme By electron capture, mostly to
The double-walled encapsulation reduces the risk of the first and second excited
states of ruthenium-103
radioactive leakage.
An excitation is almost totally by internal conversion, leading
There is another new source of iodine-125 seeds on the to the production of characteristic X-rays:
US market, designated as MED 3631-A/S and manufac- Photon energy Photons em itted
tured by North America Scientific Incorporated, North 20.1 keV 65.6%
Hollywood, California [7], This source has now been 23.0 keV 12.5%
reconfigured (MED 3631-A/M) with the intent of pro- Effective energy 21 keV
viding greater facility for radiographic source identifica-
Tenth value layer in lead 0.03mm
tion while achieving reduced isotropy [8].
10 Sources in brachytherapy

13.6 Other proposed sources [9,11] REFERENCES

The properties of other proposed sources are shown in


1. Longworth, G. (ed.) (1998) The Radiochemical Manual.
Tables 1.10, 1.11, and 1.12.
Harwell, UK, AEA Technology plc.
2. Godden, T.J. (1988) Physical Aspects of Brachytherapy,
Table 1.10 Properties of samarium-145
Medical Physics Handbooks 19. Bristol, Adam Hilger.
Photon energy range 38.2-61.4 keV 3. Walstram, R. (1965) Studies in therapeutic short distance
Mean photon energy 41keV and intracavitary gamma beam techniques. Physical
Half-life 340 days considerations with special reference to radiation pro-
tection. Acta Radial., Supplement 236,1-129.
Maximum specific activity 73 GBq mm-3 (compared with
370 GBqmm-1for iodine-125) 4. Daskalov, G.M., Loffler, E. and Williamson, J.F. (1998)
Monte Carlo-aided dosimetry of a new high dose-rate
Tenth value layer in lead 0.2mm
brachytherapy source. Med. Phys., 25, 2200-8.
Purpose To improve dose distribution 5. Nath, R., Anderson, L.L, Luxton, G., Weaverk, A.,
and shelf-life compared with
Williamson, J.F. and Meigooni, A.S. (1995) Dosimetry of
iodine-125; in addition, it is
interstitial brachytherapy sources: recommendations of
noted that the photon energy
emitted allowssensitization of the AAPM Radiation Therapy Committee Task Group
biological cells to radiation No.43. Med. Phys., 22, 209-34.
damage by the addition of 6. Nath, R. and Melillo, A. (1993) Dosimetric characteristics
iodinated deoxyuridine; there of a double wall 1-125 source for interstitial brachy-
are no commercially available therapy. Med. Phys., 20,1475-83.
sources at the present time 7. Wallace, R.E. and Fan, J.J. (1998) Evaluation of a new
brachytherapy iodine-125 source by AAPM TG43 formal-
Table 1.11 Properties of ameridum-241 ism. Med. Phys., 25, 2190-6.
8. Wallace, R.E. (1999) Report on the dosimetry of a new
Photon energy range 13.9-125 keV (but dominated by design iodine-125 brachytherapy source. Med. Phys., 26,
59.5 keV) 1925-31.
Mean photon energy GOkeV 9. Battista, J.J. and Mason, D.L.D. (1994) New radionuclides
Half-life 432 years for brachytherapy. In Brachytherapy from Radium to
Maximum specific activity 0.34 GBq mm-3 Optimization, ed. R.F. Mould, J.J. Battermann, A.A.
Martinez and B.L Speiser. Veenendaal, The Netherlands,
Tenth value layer in lead 0.42 mm
Nucletron International, 373-84.
Purpose Could be used as an alternative
10. Mason, D.L.D., Battista, J.J., Barnett, R.B. and Porter, A.T.
to cesium-137 for cancers of the
(1992) Ytterbium-159: calculated physical properties of
cervix and endometrium
a new radiation source for brachytherapy. Med. Phys.,
Disadvantages An a emitter
19, 695-703.
Only low specific activity
11. Williamson, J.F. (1995) Recent developments in basic
available
brachytherapy physics. In Radiation Therapy Physics, ed.
A.R. Smith. New York, Springer-Verlag, 247-302.
Table 1.12 Properties of ytterbium-169 [10]
Photon energy range 50-308 keV
Mean photon energy 93keV
Half-life 32.0 days
Maximum specific activity 340 GBq mm-3
Tenth value layer in lead 1.6mm
Seed dimensions Similarto iodine-125
Purpose Possible benefit-less
attenuation in tissue than
iodine-125 or palladium-153
and higher specific activity
2
Source specification and dosimetry

J.M.WILKINSON

2.1 SOURCE SPECIFICATION BY CONTENT quially as the 'k' factor, and an assumed knowledge of the
attenuating properties of the materials used in the source
construction. The specific gamma ray constant for radium
2.1.1 Radium and radium mass was defined as the product of the exposure rate, in roent-
gen per hour, and the square of the distance, in cm2, from
Early brachytherapy was practiced with two radio- a 1 mg point source, encapsulated in a platinum sheath of
nuclides from the uranium/radium series, namely 0.5 mm thickness. Early workers adopted a value of 8.4
radium-226 and its immediate daughter, radon-222. Rh-1cm-2mg-1 for this constant, but subsequently this was
Both exist in equilibrium with later radionuclides in the revised to what is now the generally accepted value of 8.25
series, and indeed their usefulness as brachytherapy Rh-1cm-2mg-1. To determine the exposure rate at a point
sources arises from the gamma emissions that occur in near to a line source required an evaluation of the Sievert
the transitions from lead-214 (referred to at one time as Integral [1]. This was originally expressed as an angular
radium B) to bismum-214 (radium C), and from integration, as illustrated in Figure 2.1, and the integral
bismuth-214 to polonium-214 (radium C'). Both itself is that given in equation 2.1:
radium and radon require heavy metal screenage (at
least 0.5 mm of platinum or gold) to remove the partic-
ulate emissions, leaving practical brachytherapy sources
with almost identical gamma spectra. Radium-226
sources were specified in terms of the mass of radium
element, in milligrams, that each contained, and, given
the very long half-life for the decay of radium, 5.85 x 105
days, it was usually regarded as unnecessary to correct
the mass specification during a period of less than about
20 years, that is to say, during the normal working life of
the source.

2.1.2 The Sievert Integral

It was anticipated that the degree of radiation damage in


tissue would be closely related to the magnitude of the
exposure. The exposure rate at a point outside a radium
source was determined by using a calculated value of the Figure 2.1 The exposure rate at point P is obtained by the
specific gamma ray constant, sometimes referred to collo- angular integration of the Sievert Integral from f1 to f2.
12 Source specification and dosimetry

where dX/dt is the exposure rate at the point P, M is the 2.1.4 Radon and radium mass equivalent
radium mass, k0 is the specific gamma ray constant cor-
rected back to zero filtration, m, is an appropriate filtra- A radon source was specified, at any particular instant in
tion coefficient, and the other symbols are as indicated time, by its radium mass equivalent, defined as that mass
in Figure 2.1. There is no analytic solution to the inte- of radium, encapsulated by a 0.5 mm thickness of plat-
gral, but tabulated values have been published (see, for inum, which would give the same exposure rate at 1 cm
example, reference 2). This approach is not too unrea- from the axis of the source. Radon-222 has a half-life of
sonable at relatively high gamma energies, but in fact 3.83 days and so both the radium mass equivalent and
represents a considerable simplification of the true the exposure rate at any defined reference point decrease
physical problem, which becomes apparent when doses during an application. Radon seeds were used both for
in the vicinity of a source are calculated by Monte superficial mould treatments and for permanent
Carlo techniques [3]. The classical Sievert Integral implantation. The total exposure for an application was
assumes that increased scattering at short distances will calculated by multiplying the initial exposure rate by an
compensate for attenuation in the irradiated medium 'effective' treatment time, determined by integrating the
to within the precision tolerances required for practical area under the exponential decay curve. The generalized
brachytherapy work. Furthermore, there is no expression for 'effective' treatment time, teff, is that in
allowance for internal absorption in the source material equation 2.2, where l, is the decay constant and t is the
itself and there is no obvious way to determine an duration of the application:
appropriate value for the filtration coefficient for the
sheathing material. Early workers used a single value of
0.2 mm-1 for filtration of radium gammas in platinum
[4], but Whyte [5] suggested that a better approxima- For a permanent implant of radon seeds, this reduced to
tion could be achieved by using decreasing values with teff = half-life/loge2, or 132.5 h.
increasing thicknesses to counter the hardening of the The use of radium and radon has now generally been
energy spectrum. discontinued due to radiation safety considerations.
Radionuclides that have subsequently been substituted
for radium and radon, for example cesium-137 or gold-
2*13 The milligram-hour concept 198, have also been specified in terms of the radium mass
equivalent as this facilitates their use with the established
Systems of brachytherapy dosimetry for radium appli- radium systems that use the milligram-hour concept.
cations were devised which dictated the relative distrib- However, such nuclides have different gamma emission
ution of active material for different treatment spectra and may be encapsulated in different materials.
geometries. Of these, the best known were the Hence the dose distribution around a substitute source
Manchester System [4, 6-9] and the Quimby System may be different from that around a radium or radon
[10-12]. Such 'systems' recognized that, for a predeter- source of similar physical dimensions. In practice, the
mined geometry and predetermined relative distribu- radium mass equivalent was frequently determined by
tion of active material, the exposure rate at any point comparing the source in question with a similar-sized
was proportional to the total amount of radium used, radium source, of known mass content, in a well-type
and that, for a complete treatment, the total exposure ionization chamber. This appears to have been satisfac-
was proportional to the product of the amount (speci- tory and there is no evidence to suggest that clinical
fied as radium mass in milligrams) and the duration results have been adversely affected by such practice.
(specified as time in hours). Hence the milligram-hour
(which was the name given to both the quantity and its
unit) became a key parameter in early brachytherapy 2.1.5 Specification by activity content
dosimetry. It was assumed that this product would
have to remain constant, for any particular source An alternative quantity for specification by content is the
geometry, in order to achieve consistency in the activity of the radionuclide that is encapsulated in the
observed clinical result. It is interesting to note that this source. The activity, A, of an amount of radioactive
assumption was, in effect, challenged at a very early nuclide, in a particular energy state and at a given time,
stage by the use of time factor corrections [13, 14], but is defined by equation:
the application of such corrections, now generally
called dose rate corrections, remains the subject of
much debate. Brachytherapy systems are discussed in where dN is the expectation value of the number of
more detail in Chapter 4. They are introduced here to spontaneous nuclear transitions from that energy state
demonstrate how the radium mass specification was a in the time interval dt [15].
fundamental component of these early clinical dosime- The early unit of activity, the curie (Ci), was originally
try procedures. defined as the activity of 1 g of radium, or approximately
Specification by emission 13

3.7 x 1010 transitions per second. A subsequent redefini- of an emission property, so avoiding errors due to uncer-
tion of the curie made it exactly this figure. The curie is tainties in the exposure rate constant or any other simi-
now obsolete as the unit of activity and has been lar parameter. At the same time dosimetry errors that
replaced by the SI unit the becquerel (Bq). One becquerel may be made when allowing for the encapsulation mate-
is one transition per second. rial will be reduced. The benefits of this approach are
In order to calculate exposure rate at a point external summarized by Jayaraman et al. [18]. Specification in
to a source specified by its activity content, it was again terms of a reference exposure rate was proposed by
necessary to assume a knowledge of the attenuating Wambersie et al. [19], and in the following year this was
properties of the source and source encapsulation mate- the subject of a formal recommendation by the National
rial, and also, now, to know the value of the exposure rate Council on Radiation Protection and Measurements
constant, Gd. This latter quantity replaces the specific [20]. However, as exposure rate has now been replaced
gamma ray constant. The two constants are very similar by air kerma rate in many aspects of fundamental radia-
in concept and for many nuclides are assigned the same tion dosimetry, specification quantities that are based on
value. However, the specific gamma ray constant does air kerma rate are now being recommended instead. The
not allow for possible contributions from internal con- French Committee on Measurements of Ionising
version X-rays, and these may be significant for low Radiations (CFMRI) [21] and the American Association
energy emitters. The definition of the exposure rate con- of Physicists in Medicine (AAPM) [22,23] have each
stant, as given in reference 16, is the quotient: independently recommended a quantity that is defined
as the product of the air kerma rate at a distance /, mea-
sured along the transverse bisector of the source, and the
square of the distance /. The distance / must be large
where(dX/dt)Gdis the exposure rate due to photons of enough that both the source and the detector may be
energy greater than 5, at a distance / from a point source treated mathematically as points. The CFMRI called the
of a nuclide containing activity A. quantity le debit de kerma normal, and the AAPM use the
The exposure rate constant is characteristic of the par- term air kerma strength. The latter term will be used in
ticular radionuclide. For radium and radon, d is deter- this chapter, but an international readership must be
mined for a point source with a filter thickness of 0.5 wary not to translate strength as force, which is the dic-
mm platinum and hence is numerically equal to the spe- tionary translation for some European languages. The
cific gamma ray constant. For all other radionuclides, the AAPM have assigned the symbol U to the unit of air
constant is determined for unfiltered emissions and kerma strength, where, for a point source:
hence a correction is required to allow for source encap-
sulation.

2.1.6 Equivalent activity


2.2.2 Reference air kerma rate
In practice, it was difficult to determine the activity con-
tent of an existing source and so the equivalent activity, Various other national and international organizations
A eq , was often used in its place [17]. This was calculated [24-27] have defined an air kerma specification quantity
by determining the exposure rate external to the source, as the air kerma rate at a reference distance of 1 m from
and then using the exposure rate constant to obtain the the center of the source. The precise wording of the def-
activity of a hypothetical, unfiltered, point source that inition differs slightly in the different publications, but
would give the same result. There is scope here for much the quantity is, in practice, the same, and several of the
confusion and possible error, particularly if those com- reports and recommendations assign the name reference
mercial computer systems that offer a brachytherapy air kerma rate. The definition given in the BIR/IPSM rec-
dosimetry package fail to specify clearly whether it is the ommendations [27] is that the reference air kerma rate is
true activity content, or the equivalent activity, that is the kerma rate to air, in vacuo, at a reference point which
required when entering source data. is 1 m from the center of the source, and that for needles,
tubes, and other similar rigid sources, the direction from
source center to the reference point is that at right-angles
to the long axis of the source. It was recognized by the
2.2 SPECIFICATION BY EMISSION
authors of the report that measurements at 1 m, in
vacua, and in scatter-free conditions, would not be pos-
2.2.1 Air kerma strength sible, and that the magnitude of the reference air kerma
rate for any given source would have to be derived from
As an alternative to using a content quantity, such as measurements made in other conditions, the most likely
radium mass, radium mass equivalent, or activity, a being ionization measurements made in air, and con-
brachytherapy source may be specified directly in terms ceivably at distances of less than 1 m. In deriving the
14 Source specification and dosimetry

reference air kerma rate from such measurements, it will ation dosimetry. Unfortunately, the ICRU has assigned
be necessary to convert the measured charge released to the same symbol Gd to both constants. The air kerma rate
a statement of energy released by using a calculated value constant is defined by the quotient:
of the average energy required to produce one unit of
ionization in air. It will also, in principle, be necessary to
correct for attenuation and scattering in air, for the
response of any detector that cannot be regarded as a where (dK/dt)d is the air kerma rate due to photons of
point detector, and for any deviation from the inverse energy greater than 8, at a distance / from a point source
square law when extrapolating from the actual measure- of the nuclide containing activity A [15].
ment distance to 1 m. Other techniques of measurement, The weakness of this approach is that different parties
and other methods of deriving the magnitude of the may adopt different values for the air kerma rate con-
specification quantity from such measurements, stant. For iridium-192 several values have been
although very unlikely, are not excluded by the proposed; for example, Godden [29] recommends
BIR/IPSM definition. 0.111 LlGyrr'm'MBq-1, whereas Dutreix et al. [30] sug-
The recommended units for the reference air kerma gest 0.1157 mGyh-1m2MBq-1. Clearly, great care is
rate are mGy h-1 for low dose-rate sources, i.e., those used required to avoid significant systematic error.
in applications where treatment durations are quoted in
hours, progressing to mGy min-1 and mGy s-1 where the
treatment durations would be expressed in minutes or 2*3 DOSE-RATE CALCULATION FROM A
seconds respectively. The air kerma strength of a source, REFERENCE AIR KERMA RATE SPECIFICATION
expressed in U, and the reference air kerma rate,
expressed in (mGy h-1, although dimensionally different, 2*3*1 Reference air kerma rate and
will be numerically the same for all practical brachyther- spherical sources with isotropic emission
apy purposes. The discussions that follow on the rela-
tionship between the older content specifications and For small spherical sources with isotropic emission, the
reference air kerma rate will therefore be equally applic- most commonly used expression for calculating the dose
able to air kerma strength. rate to water in water, dD(r)water/dt, at radial distance, r, is:

2.2.3 Radium mass equivalent and


reference air kerma rate where (dfCair/dt)ref is the reference air kerma rate specifi-
cation for the source, f(r) is a radial function describing
All advocates of source specification by emission recom- the net effect of attenuation and scattering in water, the
mend that the practice of source specification by content term in square brackets is the ratio of the mass energy
should be discontinued. However, there is a practical absorption coefficient for water to the mass energy
problem here in that many commercial software pack- transfer coefficient for air, and (djr)2 gives inverse square
ages, and some source suppliers, continue to use content scaling from the reference distance dr, (df equals 100
quantities. It is therefore necessary, at least during a tran- when r is in cm). The value of absorption coefficient to
sition period, to convert from reference air kerma rate to transfer coefficient ratio may be calculated from the data
milligram radium equivalent or to equivalent activity. published by Hubbell [31], and for photon energies
Using a specific gamma ray constant of 8.25 Rh-1cm2 between 150 keV and 1.5 MeV is in the range
mg~' for radium with 0.5 mm platinum filtration, the 1.107-1.112. Hence a single value of 1.11 may be
average energy per unit charge released by ionization in adopted without incurring serious error for most of the
air of 33.97 J C-1 [28], and taking the charge released per commonly used brachytherapy radionuclides. Strictly
unit mass of air by one roentgen of exposure to be speaking, however, this ratio is a function of photon
2.58X 104 C kg-1 [15], then a point source containing energy and care must be exercised when using this
1 mg radium equivalent will give an air kerma rate of approach with nuclides of low energy emissions and
7.23 mGy h-1 at 1 m. where the energy spectrum will be further significantly
degraded by scatter. Inverse square scaling will also break
down when very close to a finite-sized source, but this
2.2.4 Equivalent activity and reference air
has no practical dosimetric consequences.
kerma rate

To convert between reference air kerma rate and equiva- 2*3*2 Attenuation and scattering in the
lent activity requires knowledge of the appropriate air irradiated medium
kerma rate constant. With the demise of the quantities
exposure and exposure rate, the air kerma rate constant The net effect of attenuation and scattering in water has
has replaced the exposure rate constant in modern radi- been investigated both experimentally and by Monte
The AAPM recommendations 15

Carlo techniques. Meisberger et al. [32] summarize the


earlier work and recommend values for coefficients of
third-order polynomials for the function f(r). The
Meisberger polynomials became the most common cor-
rection method, but early Monte Carlo calculations [33]
suggested that these polynomials were suspect. However,
more recent Monte Carlo work, for example Sakelliou et
al. [34], is in much closer agreement. The BIR/IPSM
report [27] recommends polynomials based on
Sakelliou's work. Klevenhagen [35] demonstrated that
the polynomial approximation must break down both at
very small and at very large distances, but, as the correc-
tion is usually very small when using the common Figure 2.2 Intregral evaluated as the sum of the dose
radionuclides at short distances, this may be ignored in contributions from many small contiguous line source elements.
practice.
expression (equation 2.7). The angle convention in the
233 Seed sources above equation has been changed from the original
BIR/IPSM publication so as to be consistent with the
Small seeds containing, originally, radon, but more AAPM formalism, which will be described later in this
recently gold-198 or iridium-192, should strictly be con- chapter.
sidered as cylindrical sources. However, where a large The BIR/IPSM approach represents an improvement
number of such seeds are randomly orientated in a per- over the original Sievert Integral in as far as there is now
manent implant, a more practical approach is to treat an allowance for self-absorption in the source material,
them as point sources but to include an anisotropy cor- and in that water attenuation and scattering are
rection giving the average emissions over all angles. included, but there remains the problem of choosing
Anisotropy corrections may not be applicable, however, appropriate values for the filtration coefficients. The
when the seeds are arranged in more controlled geome- BIR/IPSM report recommends the use of the linear
tries, such as on a plaque for a superficial treatment. absorption coefficients, as opposed to the linear attenu-
ation coefficients, for the mean photon energy of the
radionuclide concerned. For the higher energy emitters
2.3.4 Reference air kerma rate and with stainless-steel encapsulation, this will be a good
cylindrical line sources approximation, but will be less good when there is a low
energy component and when significant thicknesses of
For a line source the BIR/IPSM recommendations [27] high-density, high atomic number materials are
advocate an adaptation of the Sievert Integral evaluated involved. For iridium-192 sources, for example, there
by a summation of the contributions to the total dose will be moderately large errors in local dose calculations
rate from N contiguous line source elements, each no at points close to the axis where the oblique filtration
more than 1 mm in length. thicknesses in the source material itself are relatively
Each line element is subjected to a different inverse large [36]. However, this is of academic interest only and
square scaling, to a different water absorption and scat- will not significantly affect the calculation of treatment
tering correction, and to oblique filtration corrections times for clinical applications.
for both the source encapsulation material and also for
the source material itself. With reference to Figure 2.2,
the expression for the dose rate at radial distance r and
angle 0 is: 2.4 THE AAPM RECOMMENDATIONS

2.4.1 Low energy emitters and the


general AAPM formalism
where ts(qi) is the thickness of the encapsulation mater-
ial at angle qi, and ta(qi) is the thickness of source mater- As indicated in the previous section, the BIR/IPSM
ial at the same angle measured from the source axis; ms approach is not satisfactory with low energy emitters,
and ma are the corresponding filtration correction coeffi- and indeed is starting to be suspect with iridium-192. In
cients. The ratio of water absorption coefficient to air North America, most interstitial brachytherapy is done
transfer coefficient has been given the value 1.11, assum- using seeds of either iridium-192 or the very low energy
ing that the source will be one of the higher energy emit- emitter iodine-125. Two other low energy emitters,
ters. The other symbols are as for the spherical source palladium-103 and ytterbium-169, have also been
16 Source specification and dosimetry

metry, at 1 cm from the center of a unit air kerma rate


source of that type. Thus:

It is an absolute quantity which includes considera-


tion of the source geometry, the spatial distribution of
the active material within the source, self-absorption of
the radiation and scattering within the source material,
attenuation and scattering within the encapsulation
material, and attenuation and scattering within the water
medium. As the quantity is inversely proportional to the
air kerma strength, any future systematic change in the
Figure 2.3 The geometry pertaining to the formalism
air kerma strength specification for a particular source
recommended by the MPM Radiation Therapy Task Group.
type, such as may arise from a change in calibration tech-
nique, must be accompanied by an equal and opposite
investigated for brachytherapy applications (see, for change in the value of the dose rate constant. The other
example, Meigooni et al. [37], or Chiu-Tsao and terms in the formalism are all relative quantities and
Anderson [38] for palladium, and Perera et al. [39] or normalize to unity at r=l cm and 0=71/2.
MacPherson and Battista [40] for ytterbium). The for-
malism recommended by the AAPM [23] attempts to
solve the problem by incorporating 'a direct use of mea-
sured or measurable dose distributions produced by a
2.4.3 The geometry factor, G(r,q)
source in a water equivalent medium.' However, the dif-
The geometry factor is included in the formalism to
ficulties associated with measuring low dose rates, in
enhance the accuracy of interpolation between tabulated
very high dose gradients, and with finite-sized detectors
discrete values of both the radial dose function and the
which may or may not be energy dependent, should not
anisotropy function in regions of very high dose gradi-
be underestimated, and anyone attempting to imple-
ent. Its purpose is to remove the effects of the inverse
ment this protocol should only use data that have been
square law on the dose distribution, and its use is per-
validated and approved by the appropriate AAPM task
haps most easily understood when considering the case
group. In practice, it would appear that much reliance is
of a small, spherical source with isotropic emission (i.e.,
being placed on Monte Carlo calculations. A critical
when F(r,q) is unity for all values of r and 9). In such a
review of published work on Monte Carlo calculations
case, the geometry factor takes the value of 1/r2 for all
and dose distribution measurements for those
angles, leaving the radial dose function, g(r), as a very
brachytherapy sources commonly used in interstitial
slowly varying function of radial distance describing
treatments in North America has been included with the
only the net effect on the dose rate of attenuation and
published AAPM recommendations [23]. The geometry
scattering in water.
for the AAPM formalism is shown in Figure 2.3.
For a line source it takes the value of the Sievert
In addition to the source specification quantity, air
Integral for zero filter thickness, thus:
kerma strength, symbol Sk, the general formalism intro-
duces several other new quantities. These are the dose
rate constant, A; the geometry factor, G(r,q); the radial
dose function, g(r); and the anisotropy function, -F(r,q).
For cylindrically symmetric sources, the expression for
calculating the dose rate by this formalism, is: 2.4.4 The radial dose function, g(r)

The radial dose function describes the relative variations


The symbol dD(r,q)water/dt, for dose rate to water in water in the dose to water in water along the transverse axis of
at radial distance r and angle q, has been retained so as to the source (i.e., in the radial plane of symmetry only). It
maintain consistency with the previous notation in this excludes the effect of inverse square fall off, but includes
chapter. the net effect of absorption and scattering in the
medium and, for points close to the line source, any
effects of oblique filtration in both the source and the
2.4.2 The dose-rate constant, A source encapsulation materials. It may be defined math-
ematically as:
The dose-rate constant for a particular source type is the
g(r) = [dD(r,p/2) water /dfG(r = l,p/2)]/[dD(r =l,p/2)water/dtG(r,p/2)] (2.12)
dose rate to water in water, in the radial plane of sym-
References 17

2.4.5 The anisotropy function, F(r,jq) approach will become more generally accepted in the
future. The BIR/IPSM formalism may be used with con-
The two-dimensional anisotropy function describes the fidence for steel-encapsulated cesium-137 sources, and
relative variations in dose at points away from the trans- will give very acceptable results for clinical dosimetry
verse axis of the source. It may be defined mathemati- when using high dose-rate iridium-192 stepping sources,
cally as: and for iridium wires and iridium seeds in ribbons.
However, the Sievert Integral approach is certainly not
satisfactory with the lower energy emitters and a formal-
ism based on measured parameters has its attractions,
It allows for the effects of oblique filtration in both the but the difficulties encountered in making precise and
source material and the sheathing material, the effects of accurate dose rate measurements in the immediate
internal scattering within the source, and the effects of vicinity of low activity sources are considerable.
attenuation and scattering in the surrounding water Confidence in Monte Carlo calculations in brachyther-
medium. apy suffered a setback when early attempts were sub-
jected to criticism and revision, but the more recent code
2.4.6 Anisotropy factor, q an (r) t and should be better and, when used in conjunction with
anisotropy constant, f)an measurements, offers a reasonable method of determin-
ing the parameters for use in the AAPM formalism.
The complete formalism using the anisotropy function
describes the dose distribution around individual line REFERENCES
sources. In practical cases where there are a large number
of randomly orientated small seed sources, and where
the distances involved are generally greater than the 1. Sievert, R. (1921) Die Intensitatsverteilung der primaren
source dimensions, it may be more convenient to use a Gammastrahlung in der Nahe medizinischer
point source approximation. The formalism may then be Radiumpraparate. Acta Radial., 1,89-128.
simplified as follows: 2. Shalek, R.J. and Stovall, M. (1990) Brachytherapy
dosimetry. In The Dosimetry of Ionizing Radiations, Vol. Ill,
ed. K.R. Kase, B.E. Bjarngard and F.H. Attix. San Diego,
Academic Press.
where f an (r) is the so-called anisotropy factor. It gives the 3. Williamson, J.F., Morin, R.L and Khan, F.M. (1983) Monte
averaged dose rate over all angles at radial distance r, rel- Carlo evaluation of Sievert Integral for brachytherapy
ative to the dose rate at the same radial distance, r, on the dosimetry. Phys. Med. Biol., 28,1021-32.
transverse axis. For the more common seed sources it is 4. Paterson, R. and Parker, H.M. (1938) A dosage system for
possible to replace the anisotropy factor with a distance- interstitial radium therapy. Br.J. Radiol., 1,252-340.
independent anisotropy constant without any significant 5. Whyte, G.N. (1955) Attenuation of radium gamma
loss in accuracy. Typical values of the anisotropy con- radiation in cylindrical geometry. Br.J. Radiol., 28,635-6.
stant range between 0.9 and 0.98, depending on the 6. Paterson, R. and Parker, H.M. (1934) A dosage system for
radionuclide concerned and details of the source con- gamma ray therapy. Br.J. Radiol., 7, 592-632.
struction. It should be noted, therefore, that when using 7. Tod, M.C. and Meredith, W.J. (1938) A dosage system for
this simplified formalism the calculated dose rates will use in the treatment of cancer of the uterine cervix. Br. J.
be typically 2-10% less than those on the transverse axis, Radiol.,11,809-24.
and this could result in significant error in techniques 8. Tod, M.C. and Meredith, W.J. (1953) Treatment of cancer of
where the source orientation is controlled. the cervix uteri - a revised Manchester method. Br. J.
Radiol., 26,252-7.
9. Meredith, W.J. (ed.) (1967) Radium Dosage: the Manchester
System, 2nd edn. Edinburgh, Livingstone.
2.5 SUMMARY 10. Quimby, E.H. (1932) The grouping of radium tubes and
packs to produce the desired distribution of radiation.
It is unfortunate that two authoritative, but apparently Am.J. Roentgenol. Radium Ther., 27,18-38.
contradictory, formalisms for brachytherapy dosimetry 11. Quimby, E.H. (1935) Physical factors in interstitial radium
are currently being recommended. It is particularly therapy. Am.J. Roentgenol. Radium Ther., 33, 306-16.
unfortunate that there are two air kerma specification 12. Quimby, E.H. (1947) Radium dosage in radium therapy.
quantities, which have different names and different unit Am.J. Roentgenol. Radium Ther., 57,622-7.
dimensions, but which, for practical purposes, are inter- 13. Cowell, MAC. (1937) Research into time factors in
changeable. A recent European publication [41] uses the radiotherapy. 14th Annual Report of the British Empire
American formalism in conjunction with a reference air Cancer Campaign. London, British Empire Cancer
kerma rate specification, and perhaps this hybrid Campaign, 97-103.
18 Source specification and dosimetry

14. Paterson, R. (1948) The Treatment of Malignant Disease by Sciences in Medicine. London, British Institute of
Radium and X-rays. London, Edward Arnold. Radiology.
15. ICRU (1980) ICRU Report 33. Radiation Quantities and 28. Moretti, C.J. (1992) Changes in the National Physical
Units. Washington, DC, International Commission on Laboratory standard for X-ray exposure and air kerma.
Radiation Units and Measurements. Phys. Med. Biol., 37,1181-3.
16. ICRU (1971) ICRU Report 19. Radiation Quantities and 29. Godden, T.J. (1986) Physical Aspects of Brachytherapy.
Units. Washington, DC, International Commission on Bristol, Adam-Hilger. Philadelphia.
Radiation Units and Measurements. 30. Dutreix, A., Marinello, G. and Wambersie, A. (1982)
17. ICRU (1962) ICRU Report 10c. Radioactivity. Washington, Dosimetrieen Curietherapie. Paris, Masson.
DC, International Commission on Radiation Units and 31. HubbellJ.H. (1982) Photon mass energy absorption
Measurements. coefficients from 1 keV to 20 MeV. Int.J. Appl. Radial Isot.,
18. Jayaraman, S., Lanzl, LH. and Agarawal, S.K. (1983) An 33,1269-90.
overview of errors in line source dosimetry for gamma-ray 32. Meisberger, LL, Keller, K.J. and Shalek, R.J. (1968) The
brachytherapy. Med. Phys., 10,871-975. effective attenuation in water of the gamma rays of gold-
19. Wambersie, A., Prignot, A. and Gueulette, J. (1973) A 198, iridium-192, caesium-137, radium-226 and cobalt-
propos du remplacement du radium par le caesium-137 60. Radiology, 90, 953-7.
en Curietherapie. y. Radiol. d'Electrol. Med. Nud., 54, 33. Webb, S. and Fox, R.A. (1979) The dose in water
261-70. surrounding point isotropicgamma emitters. Br.J.
20. NCRP (1974) Report No. 41. Specification of Gamma Ray Radiol., 52,482-4.
Brachytherapy Sources. Washington, DC, National Council 34. Sakelliou, L, Sakellariou, K., Sarigiannis, K. et al. (1992)
on Radiation Protection and Measurements. Dose rate distributions around Co-60, Cs-137, Au-198,
21. CFM Rl (1983) Recommendations pour la Determination des Ir-192, Am-241,1-125 (models 6702 and 6711)
Doses Absorbees en Curietherapie. Rapport du Comite brachytherapy sources and the nuclide Tc-99m. Phys. Med.
Francais'Mesuredes Rayonnements lonisants' No. 1. Biol., 37,1859-72.
Paris, Bureau National de Metrologie. 35. Klevenhagen, S.C. (1993) Oral presentation at the British
22. AAPM (1987) Specification of Brachytherapy Source Institute of Radiology, London.
Strength. Report 21. Task Group 32 of the American 36. Williamson, J.F. (1996) The Sievert Integral revisited:
Association of Physicists in Medicine. New York, American evaluation and extension to 1251,169Yb, and 192lr
Institute of Physics. brachytherapy sources. Int.J. Radial Oncol. Biol. Phys.,
23. Nath, R., Anderson, LL, Luxton, G. et al. (1995) Dosimetry 36,1239-50.
of interstitial brachytherapy sources: recommendations of 37. Meigooni, A.S., Sabnis, S. and Nath, R. (1990) Dosimetry of
103
the AAPM Radiation Therapy Committee Task Group No. Pd brachytherapy sources for permanent implant.
43. Med. Phys., 22,209-34. Endocuriether. Hypertherm. Oncol., 6,107-17.
24. BCRU (1984) Specification of brachytherapy source. 38. Chiu-Tsao, S.T. and Anderson, LL (1991)
Memorandum from the British Committee on Radiation Thermoluminescent dosimetry for 103Pd (model 200) in a
Units and Measurements. Br.J. Radiol., 57,941-2. solid water phantom. Med. Phys., 18,449-52.
25. ICRU (1985) ICRU Report 38. Dose and Volume Specification 39. Perera, H., Williamson, J.F., Li, Z., Mishra, V. and Meigooni,
for Reporting Intracavitary Therapy in Gynecology. A.S. (1994) Dosimetric characteristics, air kerma strength
Bethesda, Maryland, USA. International Commission on calibration and verification of Monte Carlo simulation for
Radiation Units and Measurements. a newytterbium-169 brachytherapy source. Int.J. Radial
26. NCORD (1991) Recommendations for Dosimetry and Oncol. Biol. Phys., 28,953-70.
Quality Control of Radioactive Sources used in 40. MacPherson, M.S. and Battista, J.J. (1995) Dose
Brachytherapy. Amsterdam, Netherlands Commission on distribution and dose rate constant for new ytterbium-169
Radiation Dosimetry. brachytherapy seeds. Med. Phys., 22,89-96.
27. Bl R/l PSM (1993) Recommendations for Brachytherapy 41. Permattei, A., Azario, L, Rossi, G. etal. (1995) Dosimetry of
169
Dosimetry. Report of a Joint Working Party of the British Yb seed model X1267. Phys. Med. Biol., 40, 1317-30.
Institute of Radiology and the Institute of Physical
3
Calibration of sources

COLIN H.JONES

3.1 INTRODUCTION mGys-1for high dose-rate (HDR) applications. The spec-


ification quantity is called the reference air kerma rate
(RAKR), which is the name used by the ICRU [1].
Although commercial suppliers of brachytherapy
sources provide a measure of source strength, it is unwise
to rely solely on this value for patient dose calculations.
3.2 REFERENCE STANDARDS AND
Manufacturers usually specify source strengths within a
TRACEABILITY
broad range of activity. Most departments planning to
provide brachytherapy should have the ability to verify
source strengths independently and to improve the over- The calibration of sources is traceable to national or
all precision of the measurement. international standards at various levels [2]. Direct
The radiation characteristics of an encapsulated traceability is established when a source or calibrator has
source are strongly dependent upon the chemical com- been calibrated at a national standards laboratory or an
position of the radionuclide, the inert filler material, accredited dosimetry calibration laboratory.
their distribution within the source, and the details of Secondary traceability is established when the source
the source encapsulation. Also in relation to source cali- is calibrated in comparison with a source of the same
bration, the presence of radioactive impurities may design and comparable strength which has direct trace-
require a storage period after initial production to allow ability or when the source is calibrated using an instru-
for the decay of short half-life isotopes. Details of the ment with direct traceability.
construction of sources are given in Chapter 1. Such Secondary traceability by statistical inference is a term
information is important, because attenuation in the that is used for multiple sources of the same activity
source capsule may significantly alter the dose distribu- from which a suitable random sample has been cali-
tion around the source and affect the dose calibration in brated with secondary traceability.
a variety of ways, especially when measurements are Remote traceability occurs if the user relies upon the
made with re-entrant ionization chambers. It is possible manufacturer's calibration as the only standard, which
for two sources of different construction to have the may, or may not, be traceable to a national or interna-
same source strengths but significantly different radia- tional standard.
tion distributions close to the sources. The possibility Ideally, brachytherapy sources used clinically should
that such differences might influence calibration mea- have calibrations with direct or secondary traceability to
surements must be taken into account. national standards.
Source specification is considered in Chapter 2. In In the UK, the traceability routes for the calibration of
summary, the source strength is specified as the air brachytherapy sources supplied by Nycomed Amersham
kerma rate, in air, at a reference distance of 1 m, cor- plc have been summarized by Rossiter [3]. The first line
rected for attenuation and scatter in air. The unit to use of traceability for this supplier's cobalt-60 sources is in
for low dose-rate brachytherapy sources is (mGy tr1 and terms of the quantity 'activity.' Reference sources were
20 Calibration of sources

compared with a base standard of cobalt-60 whose activ- source output measurements and provide assurance on
ity was measured by absolute counting at the National source air kerma rate figures provided by this major
Physical Laboratory (NPL). The air kerma rate of the source supplier and which are based on a traceability
base standard was calculated from the measured activity route to standards of activity.
and associated energy fluence, making allowances for In the USA, the National Institute of Standards and
gamma ray absorption in the capsule, in the material Technology (NIST) maintains air kerma strength stan-
itself, and in air. Radium-226 sources have been treated dards for sealed sources of iodine-125, iridium-192, and
similarly, the activity being determined by comparison cesium-137. It should be noted, however, that the
with the British National Radium Standard. Two addi- strength specification of sealed sources is in terms of air
tional methods have been used to confirm traceability to kerma strength (Sk), which is defined as the product of
national standards of source air kerma rates. The first, air kerma rate in free space, K(d), measured along the
used for both cobalt-60 and cesium-137, involved iono- transverse bisector of the source, and the square of the
metric comparisons with a standard radium-226 source, measurement distance d:
and the second the measurement of the exposure rate of
sources in a scatter-free area at NPL by a large volume
chamber (200 mm diameter) directly calibrated against
the national primary standard [4]. This work was The distance d must be large enough that both source
repeated by Rossiter et al. [5] for cobalt-60, cesium-137, and detector may be treated as mathematical points.
and radium-226, and extended to include iridium-192 Such standardization measurements are performed in
wire sources. The results, shown in Tables 3.1 and 3.2, air using air-attenuation corrections if needed. Sk has
indicate good agreement between NPL and Amersham units of mGy m2 h-1 and these units are denoted by the

Table 3.1 Comparison of air kerma rate values in vacuo at1 m distance. (Rossiter, Williams, and Bass, 1991 [5].j

137
Cs(1802MC) 18.7.89 78.70 77.79 1.012
60
Co(HR117) 18.7.89 88.71 87.77a 1.011
88.1 7b 1.006
226Ra (S5) 18.7.89 36.56 36.52 1.001
192
lr(A49945) 13.3.90 29.44 29.25 1.006
192
lr(A49946) 13.3.90 29.39 29.22 1.006

' Comparison with60Coreference source.


b
Comparison with 226Ra reference source.
NPL= National Physical Laboratory.

Table 3.2 Air kerma rate measurement uncertainties. (Rossiter, Williams and Bass, 1991 [5].)

60
Co, 137Cs, 226Ra Random Determination of secondary standard calibration factor 0.4
Source measurements 0.4
Non-random Determination of secondary standard calibration factor (all energies) 1.2
Measurement of pressure 0.1
Measurement of temperature 0.2
Measurement of distance 0.1
Air attenuation correction 0.2
Correction for finite chamber size 0.2
2.5(60Co)
Overalla 1.4 1.8(137Cs)
0.9 (226Ra)
192| r Uncertainties as above 1.4
Non-random Weighting procedure for secondary standard factor 0.4
Overalla 1.5
aQuadrature sum.
NPL= National Physical Laboratory.
Calibration methods 21

symbol U. A set of equations has been developed for [11,12]. However, ionization chambers have been used
unambiguously converting source strength estimates successfully for conventional dose-rate sources [13], and
and renormalizing published dose-rate tables, which re-entrant chambers can be used for HDR sources [14].
assume traditional quantities and units, into forms con- Baltas et al. [15] report on a comparison of different
sistent with air kerma strength [6]. These authors list the calibration methods for HDR sources, and conclude that
factors to convert source strength of a selection of satisfactory results can be obtained by both re-entrant
nuclides from apparent millicuries (mCi) to air kerma chambers and phantom methods.
strength. The factors are independent of source geome-
try, but depend on the nominal exposure rate constant
value selected by the vendor. Conversion factors applic- 3.3.1 Re-entrant ionization chambers
able to mass of radium or true activity depend upon
both source geometry and radionuclide identity. It These instruments are characterized by a cylindrical well
should be noted that because many of these conversion and an ion collection volume, which surrounds the
factors depend upon vendor choices of physical con- source approximating at 4p measurement geometry. The
stants and exposure rate constants, users should review re-entrant (well-type) ionization chamber should
source strength specification practices employed by the respond linearly throughout its measuring range; its
vendor. This is a requirement even when an independent energy response must be known and care must be taken
calibration is made, because a comparison of the mea- to ensure that when measuring high activities there is no
sured source strength with that provided by the vendor drop in sensitivity. The response of the chamber will be
is a useful and necessary quality assurance procedure. dependent upon the geometric configuration of the
Although an institution might accept the manufac- source, its filtration, and encapsulation. The use of such
turer's calibration, it is the responsibility of the institu- an instrument for intercomparison of sources requires
tion to verify that the manufacturer's stated value is great care and it is advisable for potential users to ascer-
correct. If the measured source strength disagrees with tain the characteristics of the chamber before embarking
the manufacturer's data by more than 5%, the source of on measurements. The report of AAPM Radiation
disagreement should be investigated and any unresolved Therapy Committee Task Group 40 [2] describes the
disparity should be reported to the manufacturer. In the physical characteristics of a suitable calibrator. It is rec-
case of a batch of sources, a 3% tolerance is probably ommended that the reproducibility of the calibrator
more applicable, because individual sources may differ should be better than 2% and the signal-to-noise ratio
from the mean by a greater amount. Discrepancies greater than 100:1. The response of the chamber is
greater than the accuracy limits specified by the manu- dependent on the orientation of the source and its posi-
facturer should always be explored further. For further tion in the well [16], so it is essential to devise a source
reading on this subject, the reader is referred to refer- holder that will reproduce the source positioning. It is
ence 7. also recommended that the scale factor and linearity of
each scale used on the electrometer be determined and
monitored. The collection efficiency should be better
than 99% for commercial well chambers using conven-
33 CALIBRATION METHODS
tional brachytherapy sources. The sensitivity of re-
entrant ionization chambers depends on the energy of
There are three principal methods of calibrating brachy- the photons, thus a calibrated source of one radionuclide
therapy sources. The most frequently used method cannot be used to determine the source strength of
employs a calibrated re-entrant ionization chamber. The another radionuclide. Similarly, because of dose
second method makes use of an ionization chamber to anisotropy about the source, the relative orientation of
measure the air kerma rate at a known distance from the the source axis is important for any calibrator. The
source. In the former method, calibration of the re- source should be moved through the active volume of
entrant chamber is actually achieved by use of a radia- the chamber to verify and quantitate the extent of the
tion source, the air kerma strength of which has been change in sensitivity with source position. Figure 3.1
previously measured in air. The third method uses a illustrates a typical re-entrant chamber and Figure 3.2
solid phantom into which source(s) and ion chamber shows the variation of sensitivity with source location in
can be introduced in a convenient and reproducible way. the chamber well. The source-length dependence of the
In addition, experiments have been conducted on novel chamber should also be investigated: this is best achieved
dosimetry methods [8], but are not suitable for routine by determining the chamber response for wire sources of
calibrations at the present time. different lengths. The source-length dependence may
Re-entrant chambers are preferred for the calibration also be a function of the radionuclide. Williamson et al.
of conventional low-strength brachytherapy sources [16] showed that a calibrated source of one encapsula-
[9,10], and ionization chambers measuring the air tion may not be reliable for determining the strength of
kerma rate at a distance are preferred for HDR sources a source of the same radionuclide but different encapsu-
22 Calibration of sources

Figure 3.1 Selectron Source Dosimetry System (SDS): PTW-Freiburg re-entrant (well-type) chamber with Perspex holders for LDR/MDR
Selectron sources and HDR microSelectron sources.

Figure 3.2 Relative response of SDS (PTW-Freiburg) chamber with iridium-192 source inserted at various depths.

lation. For example, two cesium-137 sources of equal 1. For each radionuclide (and encapsulation) to be
strength and of similar size but encapsulated in platinum measured, one source should be identified as the
and stainless steel, respectively, might cause different standard source. The source should be marked or
chamber responses. In practice, it is usual to use a posi- otherwise identified so that it can be recognized
tioning device to assure reproducible positioning of the at a later date. It is appropriate to ensure that the
source close to the longitudinal chamber axis and where source selected is typical of other sources in the
the chamber sensitivity is high but least dependent upon batch.
geometrical positioning of the source. 2. The standard source should be sent to an
AAPM Report 13 [17] describes the use of re-entrant appropriate calibration laboratory for calibration.
(well-type) ionization chambers for measuring different 3. The standard may be used to calibrate all other
types of brachytherapy sources. similar sources by sequential placement of the
standard source and the sources to be calibrated
Long-lived sources (cesium-137, cobalt-60 etc.) in the same geometry within the chamber and
Calibration methods 23

comparing readings. By correcting for decay of than other brachytherapy sources as the nuclide decays
the source, it is also possible to use the standard principally by electron capture emitting characteristic
source to check for long-term chamber stability X-rays at energies from 27.2 to 31.8 keV and 35.5 keV
and chamber malfunction. gamma rays. The construction of the source affects the
Short-lived sources (iridium-192, gold-198 etc.) mean energy of the emitted radiation and any calibra-
1. Identify a long-lived source as the reference tion must be made with a calibrated source of the same
source. This source may be a standard source for design as the sources being investigated.
another radionuclide. All long half-life sources should be calibrated.
2. Obtain a standard source of the appropriate The use of re-entrant chambers is illustrated further
short-lived isotope and compare this with the in the following sections, where specific calibration pro-
reference source. This intercomparison will be cedures are described.
used to establish a baseline comparison of the
relative sensitivity of the system to the two
sources. 3.3.2 In-air' method using ionization
3. Submit the standard source to a suitable chambers
calibration laboratory for calibration.
4. There are two methods that can be used to The 'in-air' measurement technique is the primary
transfer the calibration: method of determining the strength of a brachytherapy
(a) The chamber is calibrated with the short- source. Unfortunately, the method has several inherent
lived standard source, and the reference problems and, consequently, with the exception of the
source is used to check that the chamber is calibration of strong sources (used for HDR afterload-
functioning properly. This requires ing), its use is confined largely to specially equipped
temperature and pressure corrections to be laboratories. For a low strength source, the air kerma
made if unpressurized ambient air chambers rate at a large distance from the source will be low and
are used. difficult to measure; scattering from surroundings is
(b) A correction factor defined as the ratio of also a problem, for which allowance must be made.
two measurements of chamber response Measurements can be made closer to the source, but as
using the standard source is calculated. The the measurement distance is decreased, the significance
correction factor relates the response of the of the physical dimensions of both the source and the
chamber to the short-lived standard source ion chamber increase. Positioning uncertainty also
in terms of the response to the reference becomes a problem for shorter distances. In the absence
source. of a calibrated re-entrant chamber, the 'in-air' ion
5. Whichever method is used, the reference source is chamber method is a convenient means of checking the
measured every time the chamber is used to relative strengths of individual sources by comparing
calibrate the short-lived sources. the signal strength for the unknown source against that
6. After decay of the standard source, the reference for a reference source of known air kerma strength
source is used for subsequent calibrations. [13]. The method is less dependent upon the effects of
differences in encapsulation than for re-entrant cham-
Ideally, every radioactive source that is to be used in a ber measurements.
patient should be calibrated. In practice, this is not To measure low air kerma rates requires large volume
always possible. For short half-life sources such as chambers to achieve a signal-to-noise ratio better than
iodine-125 and iridium-192 seeds, traceability by statis- 100:1 and a wide range of chamber types have been
tical inference may be appropriate, depending upon the employed. One of the corrections that has to be applied
number of ribbons or seeds in the designated strength to the electrometer reading is to allow for the dose gra-
groupings under consideration. Kutcher et al. [2] recom- dient across the chamber response, which causes the
mend that if the grouping contains only a few seeds or chamber response to differ from that of a point detector.
ribbons, all seeds should be calibrated. For groupings This effect depends upon the relative position of the
with a large number of loose seeds, it is recommended chamber with respect to the source and the physical
that a random sample containing at least 10% of the dimensions of the chamber. It has been analyzed by Tolli
seeds be calibrated. For a large number of seeds in rib- [18], who provides a means of calculating a factor to cor-
bons, a minimum of 10% or two ribbons (whichever is rect for the gradient effect. This factor is referred to in
larger) should be calibrated. For sources purchased in a more detail when the calibration of HDR sources is
sterile configuration, the report recommends purchasing described.
and calibrating a single (non-sterile) seed for each desig- The ideal jig for reproducible 'in-air' calibrations
nated strength grouping. should provide mechanical rigidity without contributing
The calibration of iodine-125 seeds is traceable to a scatter to the chamber. Mechanical devices are suitable
calibration at the NIST. The dosimetry is more complex for shorter distances of 100-200 mm, but for measure-
24 Calibration of sources

ments made at much longer distances, some form of source strengths (such as those used in the HDR
optical alignment might be more appropriate. It is some- Nucletron Selectron).
times possible to make use of radiotherapy machine laser Single HDR sources (similar to those used in the HDR
alignment devices for this purpose. Corrections for Nucletron microSelectron, the Gammamed HDR
room-scattered radiation can be made by making mea- system, the CIS Curietron 192 HDR, and the Varian
surements at various distances. Room scatter, which can Varisource HDR remote afterloader).
be assumed to be constant over the distances measured, Pulse dose-rate (PDR) sources.
can be determined from examination of the data, assum-
It is good working practice when calibrating sources
ing that the dose data set after correction for room scat-
used in remote after-loading brachytherapy equipment
ter should comply with the inverse-square-law.
for a written procedure to be drawn up and followed.
The ion chamber and electrometer used for calibra-
Measurements and observations must be fully docu-
tion purposes should have a traceable calibration for
mented. Whenever possible, the definitive calibration
radiation of the same energy that is being investigated
should be derived from two independent sets of mea-
and preferably be relatively insensitive to changes in
surements made by two physicists experienced in radio-
photon energy over a wide range.
therapy, using different dose instruments. The
calibration measurement should be compared with the
supplier's certificate of calibration. When necessary, data
333 Source calibrations in solid phantoms
from the certificate of calibration should be re-calculated
using the same units and conversion factors as those
The third method of calibrating sources employs a solid
employed in the definitive calibration. Any difference
acrylic phantom, which contains a centrally placed ion
between the corrected data and the definitive calibration
chamber with two or more cavities for source catheters
must be reconciled. Using the clinical data calculated
positioned radially around the chamber. Source mea-
from these measurements, the response of a suitable
surements in a solid phantom are more reproducible and
dosimeter must be calculated for a different treatment
straightforward than 'in-air' measurements. In practice,
time from that used in the calibration. In the case of
however, for reference air kerma rate measurements,
equipment into which a value of source strength can be
allowance has to be made for phantom attenuation and
programmed, it is recommended that the calculated
scatter. Furthermore, at the point of measurement, it is
treatment time should be based on the displayed source
necessary to take into account the replacement of the
strength. The definitive calibration is confirmed if the
phantom material by the ionization chamber. These fac-
predicted reading is obtained within the limits of exper-
tors, which are characteristic of the measurement set-up,
imental uncertainty. In some situations an allowance will
are difficult to determine with precision, so the overall
have to be made for any dose that is delivered during
accuracy of the measurement is reduced. Even so, once a
transit of the source.
solid phantom has been calibrated satisfactorily, the high
In practice, to comply with the above recommenda-
reproducibility of the technique and its convenience
tions it is useful to have sufficient instrumentation to
make it very useful for routine quality assurance-type
facilitate measurements with a calibrated re-entrant ion-
source measurements.
ization chamber and also either an 'in-air' or phantom-
Some phantoms are designed to be filled with water:
type calibration measurement.
this simplifies attenuation corrections, but the need for
It is appropriate to note that, despite international
scatter and chamber displacement factors still applies.
agreement that source strength should be specified in
terms of the reference air kerma rate, it is recognized that
some commercially supplied computer software requires
source information in terms of activity. The use of such
3.4 CALIBRATION OF SOURCES USED IN
software requires great care in converting an RAKR spec-
REMOTE AFTERLOADING SYSTEMS
ification to an effective content specification. An equiva-
lent activity may be determined from the RAKR by using
The following source types are considered: the following expression:
Low dose-rate (LDR) sources in the form of wires or
ribbons (such as those used in the Nucletron
microSelectron). where Aeq is the equivalent activity, and 10-6 is the mGy to
Low dose-rate preloaded cesium-137 source trains Gy conversion factor.
(similar to those used in the CIS Curietron machine). Ft is a constant and equal to 1/3600,1/60 or 1 depend-
Multiple low dose-rate cesium-137 sources of similar ing on whether the RAKR is in mGy h-1, mGy min-1 or
strengths (such as those used in the LDR/MDR mGy s-1, respectively; dr is the distance at which the RAKR
Nucletron Selectron). is defined and is unity; and Gg is an appropriate air kerma
Multiple high dose-rate cobalt-60 sources of similar rate constant in m2 GyBq-1s-l.
Calibration of sources used in remote afterloading systems 25

3.4.1 Low dose-rate sources in the form of separated by inactive spacers (usually small ball bear-
wires or ribbons ings), all of which are contained in a flexible, stainless-
steel spring catheter. Before being used clinically, the
Remote afterloaders that are designed to treat intersti- location of individual capsules in the source train should
tially with wire sources or catheters loaded with radioac- be ascertained. One method of achieving this is by
tive ribbons are equipped with up to 20 or so channels. autoradiography and by densitometric scanning of the
These may be connected to flexible or rigid implants autoradiograph to locate the center of each source. The
using iridium-192 wires, or ribbons of cesium-137 calibration of individual source capsules is not easily
microseeds. A re-entrant-type chamber can be used to accomplished, especially when sources are very close to
determine the activity of the individual seeds. In the case each other. It is important for potential users of pre-
of the wire sources, it might be necessary to measure the loaded source trains to liaise fully with manufacturers
source strength per unit length along the wire. Special before source trains are made up. The manufacturer
scanning devices have been developed for this purpose; should be able to guarantee that the strength of each
generally, these devices are collimated detectors that can source loaded into the source train does not differ by
be used to scan the length of the wire, which may be up more than 5% from that stated. It is useful to purchase
to 135 mm. Usually, for calibration, a re-entrant ioniza- one or more source capsules for reference purposes,
tion chamber is the instrument of choice. This is best which can be used to study the effect of the steel spring
achieved by using wire that has been measured at a and also to examine the response of the re-entrant cali-
national standards laboratory. The measurement of this bration chamber when the source is moved along its lon-
wire provides a baseline value, which can be compared gitudinal axis. Individual sources encapsulated within a
against a source with a longer half-life; this reference flexible spring can be measured satisfactorily against a
source can be used to monitor chamber response over reference source either in air using an ion chamber or in
the long time periods in-between the definitive source a re-entrant chamber. Source trains with multiple
calibrations. With long wire sources, it is particularly sources are more difficult to measure with high preci-
important to use an appropriate source holder in order sion. The manufacturer is better placed to obtain infor-
to maintain the source centrally in the chamber well: off- mation about the strength of individual sources prior to
axis displacement can increase the chamber signal by up fabrication of the source trains. The user can check the
to 20%. As part of the calibration procedure, a reference relative distribution of activity by film dosimetry, ther-
curve should be constructed that shows the dependence moluminescent dosimetry (TLD), and by judicious use
of the chamber output upon the length of the source. of a re-entrant chamber, but overall it is better to obtain
This may be achieved by using a 10 mm piece of wire to as much information as possible about the strength of
measure the response for different positions of wire individual sources prior to loading of the source trains.
inside a thin, straight tube which is positioned precisely The location and relative strength of individual
along the axis of the well. The characteristics of well-type sources in a source train can also be recorded by means
chambers vary according to commercial design, but a of a device employing a highly collimated detector.
typical response with a 10 mm wire source should be
within about 2% over a 100 mm length [19]. Calibration
measurements should be made on all sources after wires
have been cut to length and sealed in catheters. 3.43 Multiple low dose-rate sources of
Steggerda and Mijnheer [20] make reference to the use similar strengths
of a solid phantom in which a 0.6 cm3 Farmer-type ion-
ization chamber is used for dose rate measurements. The To calibrate cesium-137 sources such as those used in the
Perspex phantom (see section 3.4.3) is 20 cm in diame- Nucletron LDR/MDR Selectron machine, it is necessary
ter and 15 cm high. Three stainless-steel afterloading to measure the strength of each source. This is best
catheters are positioned in the phantom at a distance of achieved with a suitably calibrated re-entrant ionization
5.0 cm from the axis of the cylindrical phantom and at chamber. The sources are cesium-137 glass beads encap-
120 angles. Although the phantom was designed origi- sulated in a 2.5 mm diameter stainless-steel pellet; a
nally for measuring Selectron sources, it can also be used machine can take up to 48 pellets. The pellets are not
for calibrating iridium-192 line sources and cesium-137 readily identifiable and are used effectively in a random
microseed trains. manner. Ideally, all pellets would have the same strength,
but in practice this is not the case. Figure 3.3 shows two
typical sets of source strength measurements. A re-
3.4.2 Low dose-rate preloaded cesium-137 entrant chamber is usually calibrated in terms of the
source trains source strength (mGy h-1 at 1 m), which produces a cur-
rent of a n A. When a chamber has not been suitably cal-
A preloaded source train consists of one or more ibrated, an alternative method of determining source
cesium-137 sources in the form of small source capsules strength must be used.
26 Calibration of sources

3. From the ratio of the measured and calculated air


kerma rates in water, the mean actual reference air
kerma rate of the set of sources can be determined.
Meertens [22] gives the following details about the air
kerma measurements and calculations.

KERMA RATE MEASUREMENTS IN WATER

The air kerma rate in water, km, was determined from


readings obtained with the ionization chamber and an
electrometer using the following formula [23]:

Figure 3.3 Source-strength frequency distribution for two


batches of cesium-137 LDR/MDR Selectron sources.

Where M is the corrected instrument reading:


Aukett [21] has described a method in which a Farmer
ionization chamber is used for the direct measurement M= MuncorPtPpPhum

of the air kerma rate in air for small, spherical cesium-


Muncor is the uncorrected instrument reading; Pt> Pp, Phum
137 sources at distances of 35-70 mm. A 2 mm Perspex
are the air temperature, pressure, and humidity correc-
build-up cap was used on the chamber, which was sup-
tion factors respectively; Pion is the ion recombination
ported centrally, in air, equidistant from three stainless-
correction factor; and Ppol is the correction factor for
steel applicator tubes, each carrying six sources.
polarity effects. The last three correction factors were
Geometry correction factors were calculated for each
assumed to be unity.
group of sources. The resultant measurement was found
Nk (Jkg-1) is the air kerma factor. The product of the
to differ from expected values by 4.4%.
correction factors pki (0.989) is given by:
An alternative method has been described by
Meertens [22]. The method is based on the use of a
phantom consisting of three parallel Perspex catheters
with a wall thickness of 0.11 cm, fixed together in a where katt (0.990) is a correction for attenuation in the
cylindrical geometry at 120 angles. A Perspex support wall and build-up cap of the ionization chamber; km
for a 0.6 cm3 graphite-walled Farmer-type NE 2505/3A (0.999) is a correction for the difference in composition
ionization chamber was mounted between the three between the wall plus build-up cap and air; kst (1.000) is
catheters parallel to their axes; the distance between each a correction for the stem effect for the employed field
of the catheters and the chamber centre was 5 cm. The size; and kce (1.000) is a correction for the effect of the
catheters and the ionization chamber were placed in a 36 central electrode on the response of the chamber during
x 32 x 20 cm (full scatter) water phantom. The tech- calibration.
nique was designed to position sources in all three The product of the correction factors ppi (0.972) to be
catheters simultaneously in such a configuration that the applied to the measurement in water for cesium-137
dose gradients through the chamber volume were mini- photons is given by:
mized. By using multiple sources (ten sources in each
catheter), the dose rate was high enough to measure sat-
isfactorily and, by eliminating dose gradients, the need to
where pwall (1.002) corrects for the difference in composi-
apply a correction factor for the finite size of the cham-
tion between the ionization chamber wall and water; pd
ber is overcome. To obtain a uniform dose rate at the
(0.970) is the displacement direction factor that corrects
point of measurement, the ten sources in each catheter
for the displacement of the effective center of the ioniza-
were distributed in two batches (2 x 5), separated by
tion chamber and is a function of the photon energy, the
50 mm above and below the level of the chamber center.
source to chamber distance, and the size of the ioniza-
The procedure designed to measure the mean source
tion chamber. This value 0.970 for the 0.6 cm3 (0.3 cm
strength of a set of sources is as follows.
radius) Farmer chamber was estimated from prelimi-
1. The air kerma rate in water at a point about 5.5 cm nary results of experiments with ionization chambers
distance from a number of sources is measured. with radii ranging from 0.1 to 0.8 cm, Pce (1.000) corrects
2. The air kerma rate in water at the same point for the for the effect of the central electrode on the response of
same set of sources is calculated for a reference air the chamber during the measurements in the water
kerma rate of 100 (mGy h-1 at 1 m in free air for each phantom. The integration time, t, applied for the ioniza-
source. tion current measurements was 0.033 h (120 s).
Calibration of sources used in remote afterloading systems 27

KERMA RATE CALCULATIONS IN WATER straight applicator and measure the air kerma rate with
the Farmer-type chamber at a distance of 500 mm. This
The contribution of one point source with a given refer- method has been described and used by Chenery et al
ence air kerma rate, Ktefy in mGyh-1 at 1 m free air to the [26] and Messina et al. [27]. The chamber used should
calculated air kerma rate Kc, in cGylr1 in water at a dis- have a calibration traceable to a national calibration lab-
tance, d, in cm from the point source was calculated oratory; it should be used with a build-up cap for cobalt-
according to the following formula: 60. For reproducible measurements, some form of
fixation device should be used to ensure that the appli-
cator and the ion chamber are parallel and held so that
the applicator is not displaced by transfer of the sources.
where S(d) is the absorption and scatter correction fac- The applicator can be metal or plastic as long as it is
tor according to Meisberger et al. [24]. rigid. If both types are available, measurements can be
made to determine the attenuation effect of the metal
applicator. Both applicator and ionization chamber
should be at least 1 m from the floor, the walls, or any
and A0 = 1.0091, B0 = -9.015 x 10-3 cnr-1, C0 = -3.459 x other large scattering medium. Room scatter will be
10-4 cm-2, and D0 = -2.817 x 10-5 cm-3. characteristic of the local environment and an estimate
Kc in the calibration point of the water phantom for should be made of its magnitude. In most situations it is
sources in the three catheters, each with a KKf value of likely to be between 3% and 4% for the source-chamber
100 mGyhr1. geometry described. The principal error is likely to be
Meertens [22] also reports on the use of a Perspex cal- associated with the position of the sources inside the
ibration phantom smaller than the water phantom but of applicator: they are not constrained to lie perfectly on
a similar design. From experiments, it was determined the axis of the applicator, but tend to zigzag, with dis-
that the cylindrical Perspex phantom 20 cm diameter placements of over 0.5 mm occurring 16% of the time
and 15 cm high gave results 4% lower than those [26]. The positional errors, including those associated
obtained with the water phantom. The measurements in with the measurement of the applicator-chamber sepa-
water had a reproducibility of 0.3% (1 SD), with an ration, produce an uncertainty in the measured dose rate
uncertainty that could not be evaluated by statistical
methods of about 1.2%.
Perspex phantoms similar to the one described ensure
good reproducibility of set-up and, once an appropriate
factor relating measurements made in Perspex to those
in water has been determined, the smaller solid phantom
can be used for routine calibration purposes.
The method has also been used by Jones [25] with a
different source configuration. Figures 3.4 and 3.5 show
the water phantom and the resultant distribution using
eight sets of five sources with a 40 mm separation
between each set of sources.

3.4.4 Multiple high dose-rate cobalt-60


sources of similar source strengths

The cobalt-60 sources used in the Nucletron remote


afterloading machine consist of 1.5 x 1.5 mm cylinders
encapsulated in titanium spheres 2.5 mm diameter;
there are 20 sources in each machine. The relative
strength of each source may be determined with a re-
entrant ionization chamber. If the chamber has not been
calibrated for these sources, a Farmer-type 0.6 cm3 ion
chamber can be used. A measurement device and source
configuration similar to that described in the preceding
section might be used, replacing the set of four sources
by a single source so that the chamber would be exposed Figure 3.4 Perspex/water calibration phantom with central
to eight sources simultaneously. cavity for Farmer chamber and four stainless-steel catheters
An alternative method is to use all 20 sources in a distributed radially at 50 mm.
28 Calibration of sources

Figure 3.5 IGE (Target) computer calculation of dose distribution of four straight Selectron catheters each loaded with 2x5
LDR/MDR Selectron pellets with 40 mm separation between each set of pellets (1.4 GBq per pellet). The calibration chamber is
positioned centrally in the region of low dose gradient. Units of distribution are cGyh-1; magnification factor (%) = WO.

of less than 1%. It should be noted that chamber leakage chamber positioned at a distance of 10-20 cm from the
should be measured, for which an appropriate correc- source; measurements with a re-entrant ionization
tion might be made. This leakage should not be greater chamber that has a calibration traceable to a national
that 0.1-0.2%. standards laboratory; and measurements with an ion
chamber and a solid phantom (or water phantom).
3.4.5 Single high dose-rate sources
IN-AIR'CALIBRATIONS
High dose-rate remote afterloading devices, such as A Joint Working Party of the BIR and IPSM recom-
those listed above (section 3.4), make use of an iridium- mended that iridium-192 HDR sources should be cali-
192 source with an activity of up to 370 GBq. brated in air with a Farmer-type 0.6 cm3 ion chamber
The source is typically in the form of a small pellet held at a distance of 100 mm from the source [28], and
(0.5 mm diameter, 4 mm active length, with a 0.3 mm that the traceability route for such measurements should
stainless-steel wall), connected to a wire that pushes and be through the external-beam standard. The recom-
pulls it through a plastic catheter to guide it to the mended method has the advantage of being widely
desired location. The half-life of iridium-192 is 73.83 applicable and experience suggests that the method pro-
days so source replacement is relatively frequent. The duces very reproducible results. It also has the advantage
principal supplier of these sources is Mallinckrodt that the purchase of additional calibration instrumenta-
Diagnostica in the Netherlands, which provides a cali- tion is not required. However, although the procedure is
bration certificate with each new source that states the straightforward, a number of interrelated factors have to
overall uncertainty in activity to be 5%. An indepen- be taken into consideration. These include the effects of
dent recalibration is required after installation of a ion chamber geometry, source-chamber distance, posi-
source before the machine is used to treat patients. tioning reproducibility, dose gradient, signal strength,
There are three methods of calibrating a single HDR and room scatter. Furthermore, because national calibra-
source: 'in-air' measurements with a calibrated ion tion laboratories do not offer calibration of ionization
Calibration of sources used in remote afterloading systems 29

chambers with the gamma ray spectrum of iridium-192,


some form of procedure must be employed to determine
an appropriate factor for the ion chamber used in the
measurement procedure. These matters have been con-
sidered comprehensively by Ezzell [29], Goetsch et al.
[12], Piermattei [30], Grimbergen and van Dijk [31],
and Biiermann et al. [32].
At a source-chamber distance of 100 mm, the correc-
tion required to allow for the fluence gradient across the
Farmer (0.6 cm3) ion chamber is 0.9% [18]. For shorter
distances, the positioning becomes more critical and a
larger factor will be required to correct for the finite
chamber size (Table 3.3). With a suitable measurement
jig, it is possible to restrict dose errors due to positional
uncertainties to less than 0.5%. Both source and detector
need to be mounted well above floor level and well away
from walls or other large structures so as to reduce the
effects of room scatter to negligible levels. Several devices
have been described in the literature, two of which are
shown in Figure 3.6. The ideal jig for reproducible 'in-
air' calibrations would provide mechanical rigidity with-
out contributing scatter to the chamber. In practice, a
small correction will be required to allow for room scat-
ter, including any scatter that might arise from the jig
itself. If it is assumed that the air kerma rate at the point
of measurement caused by room scatter does not depend
on the distance from the source, then:

where d = distance from the source to the point of mea-


surement; d0 = distance from the source to a reference
point; X = total exposure at the point of measurement;
X0 = primary exposure at the reference distance; and Xs
= room scatter exposure (assumed constant for all d).
Figure 3.6 Two 'in-air' calibration jigs: (a) Nucletron device,
The value for the room scatter correction factor at the
and (b) 'Royal Marsden Hospital device. Both jigs are shown with
distance d is then given by:
Farmer chamber without build-up cap.

Since X and d are measurable quantities and d0 is an


arbitrarily chosen distance, the values for X0 and Xs may
be determined by fitting a line to data relating X to d.
Table 3.3 Dose gradient correction factors for NE 2571 Farmer Ezzell [29] used this method and obtained data at 200,
0.6 cm3 ion chamber as a function of distance from a point 300, 400, and 500 mm from the source. The average
source to chamber center. reading at each point was corrected for leakage and timer
error and the reference distance was chosen to be
200 mm. The four data points fell on a straight line with
a correlation coefficient of unity. The author concluded
1.0 1.342 that, for the calibration jig used and at a reference dis-
2.0 1.116 tance of 200 mm, room scatter was 0.6% of the mea-
5.0 1.026 sured dose.
10.0 1.009 A similar series of measurements was made by
15.0 1.005 Goetsch et al [12] using an Exradin A3 spherical cham-
20.0 1.004
ber of 3.6 cm3 with air-equivalent plastic walls (includ-
(T6lli,1997,[18].) ing cap) at nominal distances from 100 mm to
30 Calibration of sources

396.4 mm from an iridium-192 source. The room scatter parison ratio between the field instrument and a sec-
at a source-chamber distance of 200 mm was found to ondary standard, and a calibration factor for the sec-
be 0.63%. Table 3.4 summarizes both sets of measure- ondary standard appropriate to this energy. The former
ments. For relatively large distances, and in the typical component may be determined using an iridium source
hospital laboratory, room scatter may introduce errors at sufficiently large distance to ensure that the correction
that are not negligible. As an extended time period will for finite chamber size will be the same for the two detec-
be required to collect sufficient charge for acceptable tors. The second component is more difficult to estab-
precision, it is important that leakage for the electrome- lish. The reason for this is that there is an absence of
ter system is measured and, if necessary, an appropriate primary standards for radiation from iridium-192
correction made. sources and the calibration factor of the chamber has to
Iridium-192 has a very complex emission spectrum be obtained by other means. In the UK, no factor for cal-
which includes approximately 24 lines occurring in the ibration against the primary standard is normally avail-
energy range 9-885 keV. The lowest energy emissions able between that for heavily filtered 280 kVP X-rays (for
are attenuated by the source capsule and do not influ- use with measurements made without a build-up cap)
ence measurements. The exposure-weighted average of and that for 2 MV X-rays (for use with measurements
the remaining lines is 397 keV, which falls approximately made with a build-up cap). In the USA and in some
halfway between the cesium-137 gamma ray energy of European laboratories, a factor for calibration against
662 keV and the average energy (146 keV) of a 250 kVP cesium-137 (gamma ray energy of 662 keV) is also avail-
medium-filtration X-ray beam (half value thickness = able. The subject has been discussed comprehensively by
3.2 mm Cu). For a beam of this radiation quality, the Grimbergen and van Dijk [31] and Goetsch et al. [12].
choice of calibration factor and choice of build-up cap The method described by Goetsch is a linear interpo-
are not straightforward. There are three factors to con- lation between a medium filtered 250 kV X-ray quality
sider. First of all, Goetsch et al. [12] have demonstrated and cesium-13 7, with correction for differences in wall
that for in-air measurements at short distances, it is nec- attenuation between X-rays, cesium-137, and iridium-
essary to exclude high-energy photoelectrons emitted 192 radiation. The correction factor was derived from
from the source capsule. This can be achieved either by wall attenuation measurements with one type of ioniza-
placing a build-up cap over the ion chamber or by intro- tion chamber. This method is used extensively in the
ducing the source itself into a narrow-bore Perspex tube USA and forms the basis of calibrating iridium-192
where a wall thickness of 1 mm will be sufficient to sources that are subsequently used in the calibration of
remove the electron contamination. Secondly, Goetsch et re-entrant ionization chambers.
al [12] have also suggested that iridium-192 measure- Grimbergen and van Dijk describe the air kerma cali-
ments require that the ionization chamber's wall thick- bration procedure that can be provided by the
ness must be sufficient to provide charged particle Netherlands Measurements Institute (NMI), which is
equilibrium for the highest energy secondary electrons based on weighting the chamber response according to the
present. These authors conclude, from measurements air kerma spectrum of the iridium-192 source [5]. This
made with ion chambers that have graphite caps of var- 'energy response curve' method is probably the most accu-
ious thicknesses, that the total thickness of wall and cap rate, but is time consuming and expensive to realize. The
should be at least 0.3 g cm-2 to assure charged particle authors calculated the photon spectrum of iridium-192
equilibrium: a Farmer-type chamber has a wall of source-type used in the microSelectron HDR afterloading
0.065 g cm-2. equipment using the EGS4 Monte Carlo System. The
The third consideration concerns the instrument cali- energy response was calculated for two widely used ion
bration factor. There are two components: an intercom- chambers: the NE 2561, which is used in the UK as a sec-
ondary standard, and the NE 2571, which is used as a field
instrument. The calibration of the chambers was per-
formed against the primary standards in beams of X-rays,
cesium-137, and cobalt-60 gamma radiation; during the
measurements the chambers were fitted with build-up
caps. To determine the chamber response at the energy of
5.0 1.00 each iridium-192 spectrum line, a polynomial was fitted
10.0 0.999 0.999 through the chamber calibration data (see Figures 3.7 and
15.0 0.997 0.997 3.8). A comparison was then made for each chamber: a cal-
20.0 0.994 0.994 ibration factor was derived using the 'energy response
30.0 0.988 0.986 curve' method and also one was derived using the average
40.0 - 0.975 of the medium filtered 250 kV X-ray and cesium-137 cali-
50.0 0.966 - bration factors. It was found that for both chambers the
' For local conditions as described by Ezzell (1989) [29], and Goetsch et two-point method results in a 0.3% lower value than that
a I. (1991) [12]. derived by matching the energy response curves. The
Calibration of sources used in remote afterloading systems 31

and build-up caps. These data are also presented in IAEA-


TECDOC1079 [7] together with a description of an in-air
calibration using the method based on the technique by
Goetsch et al, [12]. The principle of the method for cali-
brating an 192Ir HDR source, is to calibrate it at an appro-
priate X-ray quality and at 137Cs, or in 60Co if a 137Cs beam is
not available. With the knowledge of the air kerma calibra-
tion factors at these two energies, the air kerma calibration
Image Not Available factor for 192Ir is obtained by interpolation making use of
the wall correction factors. This method requires the total
wall thickness to be the same at each quality that the cham-
ber is calibrated.
In the UK, a Joint BIR and IPSM Working Party [28]
set up to report on brachymerapy dosimetry recom-
mended that the calibration for use with iridium should
be that for the highest available kilovoltage quality, that
is, the factor for heavily filtered 280 kV X-rays. This rec-
Figure 3.7 Energy response (E) of the NE2561 (S/N 051) with ommendation was made in the absence of a primary cal-
build-up cap. The error bars indicate two standard deviations. ibration for iridium-192. It was also suggested that the
The line is the polynomial fit used to determine the response at measurements should be made with an NE 2 MV build-
the iridium-192 spectrum energies. (Reproduced with permission up cap, or a Perspex sheath around the source to remove
from Grimbergen and van Dijk, 1995 [31].) photoelectrons emitted from the source capsule. The
recommended values for electron filter corrections are
1.017 for the NE 2 MV build-up cap, or 1.004 for a 1 mm
thick Perspex sheath around the source; more generally,
for small thicknesses of low atomic number filter mater-
ial, the recommended correction is 3% g-1 cm-2.
It is estimated that, whichever method is used to
ascertain the chamber factor, the difference between the
'energy response curve' method, the two-point method,
or the simpler 250 kV factor method is less than 1%.
Image Not Available Typical exposure times for an 'in-air' calibration at
100 mm using a nominal 10 mGy s-1 source will be about
300 s. If the mean reading is R then the RAKR, Kr in
mGy s-1 is derived as follows:

Fc is the air kerma calibration factor for the secondary


standard;
F.c is the intercomparison ratio between the field
Figure 3.8 Energy response (E) of the NE 2571 (S/N 1436) with
instrument and the secondary standard;
build-up cap. The error bars indicate two standard deviations.
Ftp is the temperature/pressure correction factor
The line is the polynomial fit used to determine the response at
(= TIP x 1013/293.2), where T is the temperature
the iridium-192 spectrum energies. (Reproduced with permission
in Kelvin and P the pressure in millibar;
from Grimbergen and van Dijk, 1995 [31].)
Fs is the correction for room scatter and scatter
produced in the jig and its support (= 0.998 for the
Royal Marsden jig and support system);
uncertainty in the calibration factor for iridium-192 Fg is the dose gradient correction factor for the ion
determined with the energy response curve method was chamber (= 1.009 for a 0.6 cm3 Farmer-type
estimatedat l%fortheNE2561 and l.l%for the NE 2571. chamber at 100 mm);
It is concluded by Grimbergen and van Dijk [ 31 ] that, with Fe is the electron filter correction (= 1.017 for an NE
respect to the chambers considered, the two-point build-up cap);
method is a reasonable alternative to the energy response Fis is the inverse square scaling from 100 mm to 1 m
method. More recently, Ferreira et al. [33] have performed (= 10-2);
Monte Carlo calculations of chamber wall correction fac- Fm is the gray to microgray conversion (= 106);
tors for 51 commercially available ionization chambers t is the time, in seconds, for each reading.
32 Calibration of sources

In principle, there should also be corrections for air three different manufacturers. Agreement was found to
attenuation and scattering and for the source transit be within 1%.
time, but both of these are taken as unity. In order to obtain maximum reproducibility, mea-
surements in a re-entrant chamber should be made with
the aid of a Perspex insert. For definitive calibration
RE-ENTRANT IONIZATION CHAMBER
measurements, the chamber should be located away
MEASUREMENTS
from objects that might cause radiation scatter (such as
The most convenient means of measuring the strength a laboratory wall). Consistent readings are obtained best
of an HDR iridium-192 source is to use a re-entrant ion- when the chamber is used each time in the same position
ization chamber. The Standard Imaging HDR 1000 Ion and in a reproducible manner.
Chamber is designed specifically for high strength
sources [14]. The well of the chamber consists of a SOLID PHANTOM (OR WATER PHANTOM)
35 mm diameter x 122 mm deep cavity into which a MEASUREMENTS
holder can be inserted to carry a catheter or rigid appli-
The underlying principle of this type of measurement
cator for positioning the radioactive source. The respon-
has been described in section 3.4.3, except that in the
sivity of the chamber is affected by source position, but
case of a single HDR source, the dose gradient through
the variation is only 0.5% over a range of 25 mm near
the centrally placed ion chamber has to be corrected for
to the center of the chamber axis.
[18]. The method has been described by Ezzell [29], and
Jones [34] used a modified Standard Imaging cham-
Krieger [35].
ber with an NE 2571/1 electrometer as part of a quality-
Measurements in a phantom require corrections to be
assurance programme for checking iridium-192 source
made for attenuation and scatter. Usually, the effective
strengths. The chamber measurements were found to
distance between the source and the attenuation is deter-
correlate well with 'in-air' calibration measurements
mined using a formula that applies to the condition of
made over a 3-month source-decay period; the maxi-
full scatter. Generally, the small dimensions of the solid
mum discrepancy between the 'in-air' measurement and
(acrylic) phantom do not fulfil this requirement and a
the re-entrant chamber measurement was 0.9% (Figure
correction factor has to be applied to compensate for this
3.9). A further investigation with a Nucletron Source
lack of scatter. Ezzell [29] measured this to be 1.079 for a
Dosimetry System (PTW-Freiburg re-entrant ion cham-
130 mm diameter x 130 mm long acrylic cylinder.
ber) calibrated at NIST and a modified Standard
Imaging chamber showed that, over a 4-month period,
13 comparative measurements made with both cham- 3.4.6. Pulse dose-rate sources
bers were found to be within 0.18% (1 SD). The air
kerma strength measured using the NIST traceable Pulse dose-rate (PDR) sources are of lower activity than
Nucletron PTW chamber was found to agree within HDR sources and are of different physical construction.
0.3% of the 'in-air' calibration measurement. PDR sources are typically 18-37 GBq in activity. In the
Goetsch et al. [29] also report measurements using case of iridium-192, the active length of a 37 GBq PDR
three re-entrant ionization chambers manufactured by source is 0.5 mm. The most convenient method of cali-
brating such a source is to use a re-entrant ion chamber.
It will be necessary to ensure that the chamber has been
calibrated for PDR sources rather than, or as well as,
HDR sources.
The strength of the source is such that an 'in-air' calibra-
tion with a 0.6 cm3 Farmer ion chamber is achieved best at
a distance of about 50 mm; greater distances would
require extended exposures. At this short distance, it is
important to ensure precise alignment between the source
and the chamber center. The location of the source center
should be ascertained (by autoradiography) so that align-
ment can be achieved reproducibly. It is necessary to use a
build-up cap (or a Perspex sheath over the source), as
described in the section on HDR source calibration, to
remove electrons emitted from the source capsule. A cor-
Figure 3.9 The relative source strength of an iridium-192 rection for the finite size of the chamber must be applied:
source as a function of time measured with a modified standard this increases significantly at short distances. Tolli [18] has
imaging HDR WOO chamber over a 3-month period. The line shown that, for a chamber of the same dimensions as a
corresponds to the decay curve; the points correspond to 0.6 cm3 Farmer chamber, the correction factor is 1.026.
chamber measurements [34]. Exposure times to accumulate sufficient charge will be
References 33

long (typically 0.5 h) and an allowance must be made for calibration of iridium-192 high dose rate sources. Int. J.
any chamber leakage that occurs during the measurement Radial Onc. Bio/. Phys., 24,167-70.
period. 15. Baltas, D., Geramani, K., lonaddis, G.T. et al. (1999)
Comparison of calibration procedures for 192lr high dose
rate brachytherapy sources. Int.J. Radial Oncol. Bio/.
REFERENCES
Phys., 1,43(3), 653-61.
16. Williamson, J.F., Morin, R.L and Khan, F.M. (1983) Dose
1. International Commission on Radiation Units and calibrator response to brachytherapy sources: a Monte
Measurements (1985) Dose and Volume Specification for Carlo and analytic evaluation. Med. Phys., 10(2), 135-40.
Reporting Intracavitary Therapy in Gynaecology, Report 17. AAPM Report No. 13 (1984) Brachytherapy. In Physical
38. Bethesda, Maryland, ICRU. Aspects of Quality Assurance in Radiation Therapy. New
2. Kutcher, G.J., Cola, L, Gillin, M. etal. (1994) York, American Institute of Physics, 38-9.
Comprehensive QA for radiation oncology: Report of 18. Tb'lli, H. (1997) Ionisation chamber dosimetry for
AAPM Radiation Therapy Committee Task Group 40. Med. brachytherapy. Doctoral dissertation. University of
P/7ys.,21(4),581-618. Goleborg, 15-31.
3. Rossiter, M.J. (1990) The traceability of brachytherapy 19. Schaeken, B., Vanneste, F., Bouiller, A. et al. (1992) 192Tr
sources supplied byAmersham International. Br.J. brachytherapy sources in Belgian hospitals. Nucl. Insl
Radiol., 63,663. Methods Phys. Res., A312,251 -6.
4. Read, L.R., Burns, J.E. and Liquorish, R.A.C. (1978) 20. Steggerda, M.J. and Mijnheer B. (1994) Replacement
Exposure-rate calibration of small radioactive sources of corrections of a Farmer-type ionisation chamber for the
cobalt-60, radium-226and caesium-137. IntJ.Appl. calibration of Cs-137and lr-192 sources in a solid
Radial /sof.,29,21-7. phantom. Radiother. Oncol., 31,76-84.
5. Rossiter, M.J., Williams, T.T. and Bass, G.A. (1991) Air 21. Aukett, R.J. (1991) A technique for the local measurement
kerma rate calibrations of small sources of cobalt-60, of air kerma rate from small caesium-137 sources, fir. J.
caesium-137, radium-226and iridium-192. Phys. Med. Radiol., 64,918-22.
fi/o/., 36(2), 279-84. 22. Meertens, H. (1990) In-phantom calibration of Selectron-
6. Williamson, J.F. and Nath, R. (1991) Clinical LDR sources. Radiother. Oncol., 17,369-78.
implementation of AAPM Task Group 32 23. Mijnheer, B.J., Aalbers, A.H.L, Visser, A.G. and
recommendations on brachytherapy source strength Wittkamper, F.W. (1986) Consistency and simplicity in the
specification. Med. Phys., 18(3), 439-48. determination of absorbed dose to water in high-energy
7. IAEA-TECDOC-1079 (1999) Calibration of Brachytherapy photon beams: a new code of practice. Radiother. Oncol.,
Sources. Vienna, International Atomic Energy Agency. 7,371-84.
8. Mcjury, M., Tapper, P.D., Cosgrove, V.P. et al. (1999) 24. Meisberger, LL, Keller, R.J. and Shalek, R.J. (1968) The
Experimental 3-D dosimetry around a high dose rate 192lr effective attenuation in water of the gamma rays of gold
source using a polyacrylamide gel (PAG) dosimeter. Phys. 198, iridium 192, cesium 137, radium 226, and cobalt 60.
Med. fi/o/., 44(10), 2431-44. Radiology, 90,953-7.
9. Berkley, L.W., Hanson, W.F., and Shalck, R.J. (1981) 25. Jones, C.H. (1991) Quality assurance in brachytherapy
Discussion of the characteristics and results of using the Selectron-LDR/MDR and microSelectron-HDR.
measurements with a portable well-ionisation chamber Activity, 5(4), 12-15. Leersum, The Netherlands,
for calibration of brachytherapy sources. In Recent Nucletron BV.
Advances in Brachytherapy Physics, ed. D.R. Shearer, 26. Chenery, S.G.A., Pla, M. and Podgorsak, E.B. (1985)
Monograph No. 7. New York, AAPM, 38-48. Physical characteristics of the Selectron high dose rate
10. Weaver, K.A., Anderson, LL and MeliJ.A. (1990) Source intracavitaryafterloader. Br.J. Radiol., 58,735-40.
calibration. In Interstitial Brachytherapy: a Report by the 27. Messina, C.F., Ezzell, G.A., Campbell, J.M. and Orton, C.G.
Interstitial Collaborative Working Group, ed. L.L. (1988) Commissioning the Selectron HDR cobalt-60.
Anderson, New York, Raven Press. Activity, 2, 5-10. Leersum, The Netherlands, Nucletron.
11. Flynn, A. and Workman, G. (1991) Calibration of a 28. Aird,E.GA, Jones, C.H.,Joslin,C.A.F.efo/. (1993)
microSelectron HDR iridium-192 source. Br.J. Radiol., 64, Recommendations for brachytherapy dosimetry: Report of
734-9. a Joint Working Party of the BIR and IPSM. London, BIR,
12. Goetsch, S.J., Attix, F.H., Pearson, D.W. and Thomadsen, 1-17.
B.R. (1991) Calibration of Ir192 high dose rate afterloading 29. Ezzell, G. (1989) Evaluation of calibration techniques for
systems. Med. Phys., 18,462-7. the microSelectron HDR. In Brachytherapy2, ed. R.F.
13. Jones, C.H. (1988) Quality assurance in gynaecological Mould. Leersum, The Netherlands, Nucletron, 61 -9.
brachytherapy. In Dosimetry in Radiotherapy Vol. 1, 30. Piermattei, A., Azario, L, Soriani,A. et al. (1995) Reference
Vienna, IAEA, 275-90. air kerma rate determination for iridium-192
14. Goetsch, S.J., Attix, F.H., Dewerd, LA. and Thomadsen, brachytherapy sources. Phys. Med. 9-15.
B.R. (1992) A new re-entrant ionisation chamber for the 31. Grimbergen, T.W.M. and van Dijk, E. (1995) Comparison of
34 Calibration of sources

methods for derivation of iridium-192 calibration factors 34. Jones, C.H. (1995) HDR microSelectron quality-assurance
for NE2561 and NE2571 ionisation chambers. Activity, studies using a well-type ion chamber. Phys. Med. Biol.,
Special Report No. 7, 52-6. Leersum, The Netherlands, 40,95-101.
Nucletron BV. 35. Krieger, H. (1991) Messungder Kenndosisleistung
32. Biiermann, L, Kramer, H.M. and Selbach, H.J. (1995) punktund linien-formiger HDR iridium-192
Reference Air Kerma Rate Determination of an Iridium-192 Afterloadingstrahlermiteinem PMMA-
Brachytherapy Source. Activity: Special Report No. 7. Zylinderphantom.Ze/f. Med. Physik., 1,38-41.
Nucletron-Oldelft, Leersum, The Netherlands, 43-47.
33. Ferreira, I.H., Marre, D., Bridier, A., Marechal, M.H. and de
Almeida, C.E. (1999) Personal communication.
4
Systems of dosimetry

ANNE WELSH AND KAREN D'AMICO

4.1 INTRODUCTION 4.2 NON-GYNECOLOGICAL TREATMENT


SYSTEMS
Brachytherapists have always aimed to deliver the opti-
mum treatment to the patients in their care. In order to 4.2.1 The Paris System
achieve this ideal, the introduction of brachytherapy was
soon followed by the development of dosimetry systems BASIC PRINCIPLES
which were based on clinical experience. A paper on the
The first account of this system was published in 1966
physics of brachytherapy was published in 1923 by
[5] and was followed by several more detailed publica-
Coliez [ 1 ] and this was followed by many other publica-
tions, e.g., in 1978 and 1987 [6,7].
tions.
The Paris System is designed for modern sources,
The well-known Manchester System [2] was pub-
particularly iridium-192 wires, which have narrow
lished in 1934, followed by the Quimby System in 1944
diameter, are flexible, and may be formed to any length
and 1953 [3,4]. The early systems were designed for
required. The system requires the brachytherapist to
radium. Subsequently, the Paris System [5,6] was pub-
distribute sources over a predetermined target volume in
lished as a modern dosimetry system which allows the
accordance with the system rules. Dose rates are then
brachytherapist to take full advantage of the technologi-
calculated at defined points, known as basal dose-rate
cal improvement in source production, in particular the
points, within the target volume. The isodose that closely
use of iridium-192 flexible wire sources.
envelopes the target volume may be found by calculating
The aim of all the published dosimetry systems is sim-
85% of the average basal dose rate.
ple: to provide a set of guidelines for the brachytherapist
The basic rules for positioning the sources are as fol-
which, if followed, enable a prescribed dose to be deliv-
lows:
ered to the patient as accurately as possible.
This chapter contains brief descriptions of the systems Each source must be implanted parallel to the others.
most commonly used and some sample data to enable a Each source must be equidistant from adjacent
limited number of practical calculations to be per- sources.
formed. It is recommended that the original works The reference air kerma per unit length of source is
describing the dosimetry systems are consulted before constant for all the sources used in the implant.
any of the systems described are set up for clinical use for Ideally, the centers of all the sources are contained in a
the first time. single plane which perpendicularly bisects the
36 Systems of dosimetry

sources. This plane is called the central plane of the


implant. If such a plane cannot be defined, the central
plane is that plane perpendicular to the sources which
passes as closely as possible to the source centers.
The perpendicular distance between two adjacent
sources is referred to as the source separation in this
chapter. The source separation must lie in the range 8-15
mm for short wires (i.e., 50 mm or less) and 8-22 mm
for long wires (greater than 70 mm). If the source sepa-
ration exceeds the maximum permitted, there will be an
unacceptably large high dose area around each source.
This is illustrated in Figure 4.1. If the wire separations
are less than 8 mm, it is difficult to implant the wires in
a parallel fashion and the implant may not conform to
the requirements of the Paris System. Figure 4.1 Two implants each showing the area receiving the
prescribed dose and twice the prescribed dose. The diameter of

POSITIONING THE SOURCES the high dose area is considerably larger for the implant with
the greater wire separation.
The first planning consideration is the size of the target
volume. The target volume has three dimensions, which
are usually referred to, in the Paris System, as the length,
the width, and the thickness (Figure 4.2). The sources are
positioned parallel to the length dimension and may be
implanted in one or more planes, depending on the
thickness of the treatment volume.
Practical planning commences by determining the
number of source planes and the source separation nec-
essary for the satisfactory treatment of the patient.
For a single plane containing only two sources, the
source separation is given approximately by:
wire separation = thickness x 2.0
Figure 4.2 The relationship between the wire positions, the
For a single plane implant containing three or more safety margins, and the target volume dimensions.
sources, the source separation is given approximately
by:
wire separation = thickness x 1.7
edge of their planned volume. The safety margin then
The number of sources needed to implant a target vol- fulfils the purpose of its name and provides a small addi-
ume can then be calculated from: tional margin around the volume.
If the calculated wire separation exceeds the maxi-
width = wire separation x (number of wires - 1) + safety margin x 2
mum permitted value, the implant cannot be carried out
The safety margins for the different wire arrange- as a single plane of sources and two or more planes must
ments are summarized in Table 4.1. Some brachythera- be implanted. In multi-plane implants the sources may
pists prefer to omit the safety margin from their be implanted on a square lattice ('in squares') or an equi-
planning calculations and implant the sources up to the lateral triangular lattice ('in triangles') (Figure 4.3).

Table 4.1 Safety margins as fractions of wire separations for implants planned in accordance with the Paris
System rules

0.37 0.27 0.15


Non-gynecological treatment systems 37

source length = 1.4 x target volume length


All the formulae given above are approximate, but are
sufficiently accurate for clinical use. Detailed tables may
be found in reference [7].

CALCULATION OF THE DOSE

The isodose that encloses the target volume is known as


the reference isodose. It is calculated from the basal dose-
rates, which are the lowest dose rates found within the
central plane. For a single-plane implant, the basal dose-
rate points are positioned at the midpoint of each gap
between the sources. The basal dose-rate points for an
Figure 4.3 Cross-sections through two double-plane implants, implant in squares are at the center of the squares, and
one implanted 'in triangles' and one implanted 'in squares'. The for implants in triangles the basal dose rates are calcu-
dots indicate the wire positions and the crosses indicate the lated at the points where the perpendicular bisectors of
basal dose points. the sides of the triangles intersect.
The dose rates can be calculated by entering the source
position data into a suitable computer program, which is
For an implant in squares, the wire separation can be likely to be available in most oncology centers, or by
calculated from: hand calculation using graphs or tables of dose rate
against distance from the source for unit activity. The
thickness = wire separation + safety margin x 2 dose rates taken from graphs or tables must be corrected
For an implant in triangles, the wire separation can be to values for the actual mid-implant source strength.
calculated from: This will involve obtaining the source strength from the
supplier's measurement certificate and correcting it for
thickness = wire separation x 0.87 + safety margin x 2 radioactive decay to the date of the middle of the
The width of an implant in squares is given by: implant. Sample data are given in Tables 4.2a and 4.2b. A
simple example of an application of the Paris System is
width = number of squares x source separation + shown below.
safety margin x 2
The width of an implant in triangles is given by:
EXAMPLE
width = number of triangles x source separation x
A target volume 55 mm long, 8 mm thick, and 35 mm
0.5 + lateral safety margin x 2
wide is to be given a dose of 30 Gy. Calculate the source
The length of the sources required to treat a target vol- lengths required and the dose rate assuming an air kerma
ume is almost independent of the other parameters and rate source strength of 800 nGy h-1 mm-1 at 1 m halfway
is given approximately by the expression: through the implant.

Table 4.2a Sample dose rates for iridium-192, 0.3 mm diameter wire sources, calculated according to the recommendations of the
Joint BIR/IPSM Brachytherapy Working Party [8]

20 100

10 350 104 48.0 27.7 12.5 7.1 4.5 3.1 1.7 1.0
20 489 176 88.3 52.4 24.3 13.9 8.9 6.2 3.4 2.0
30 547 219 118 72.6 35.0 20.3 13.2 9.2 5.1 3.1
40 577 246 138 88.4 44.4 26.3 17.2 12.0 6.7 4.1
50 595 262 153 101 52.3 31.6 20.9 14.7 8.2 5.1
60 606 275 164 110 59.1 36.3 24.3 17.3 9.3 6.1
80 619 290 179 124 69.5 44.2 30.3 21.8 12.6 7.9
100 627 299 188 132 76.9 50.2 35.1 25.7 15.1 9.6
120 631 305 194 138 82.3 54.9 39.0 28.9 17.3 11.1
Dose rates a re in mGyh-1 for an air kerma rate source strength of 1 mGy h-1 mm-1 at 1 m. All the dose rates are for crossline = 0, i.e., in the plane
through the center of the wire and perpendicular to it.
38 Systems of dosimetry

Table 4.2b Sample dose rates for iridium-192, 0.3 mm diameter wire sources, calculated according to the recommendations of the
Joint BIR/IPSM Brachytherapy Working Party [8]

50 0 595 262 153 101 52.3 31.6 20.9 14.7 8.2 5.1
50 10 581 251 145 95.2 49.9 30.4 20.3 14.4 8.1 5.1
50 20 487 200 116 78.0 43.0 27.2 18.7 13.5 7.8 4.9
50 30 139 98.9 71.4 53.9 22.7 22.8 12.1 9.3 7.3 4.7
100 0 627 299 188 132 76.9 50.2 35.1 25.7 15.1 9.6
100 30 606 278 170 117 66.9 43.8 30.9 22.9 13.8 8.9
100 50 319 157 103 74.9 46.8 32.7 24.2 18.6 11.8 7.9
Dose-rates are in mGy h-1 for source strengths of 1 u.Gy h-1 mm-1 at 1 m. The dose rates are for different crosslines, i.e., in different planes
perpendicular to the wire and at the crossline distance from the wire center.

Single plane implant. Treatment time may be calculated from this dose rate
and the prescribed dose.
Source separation = 1.7 x thickness
= 1.7x8 = 14 mm
Width =2 x 0.37 x 14 +14 x (number of
wires -1)
= 2 x .37 x 14 + 14 x 2 = 38 mm
The isodose distribution for this implant is shown in
This is the closest width to the required value and
Figure 4.4.
requires three wires to be used.
Wire length = 1.4 x 55 = 77 mm - use 80 mm. PROBLEMS
The details of the distances and dose rate calculations for It is unlikely that an implant that conforms perfectly
this calculation are given in Table 4.3. with the Paris rules can be achieved without the use of
The mean basal dose rate for a source strength of 1 a template to aid the source positioning. If the implant
1-iGy h-1 mm-1 at 1 m, from Table 4.3, is does not comply precisely with the rules, the Paris
System may still be used providing none of the indi-
0.5 x (943 + 943) = 943 mGy h-1
vidual basal dose rates differs from the mean basal dose
Correcting this to true source strength available for use: rate by more than 10% and if, when using the triangu-
lar formation of sources, none of the triangles is obtuse
(Figure 4.5). Further information on dealing with
variants in source position which may be needed in
practice may be found in the book Modern Brachy-
therapy [7].

_ 85
Reference dose rate average basal dose rate
~100 X

Table 4.3 Dose rates calculation for sample iridium-192


imnlnnt

1 7 412
2 7 412
3 21 119
943
Dose rates in mGy h-1 calculated for wire of air kerma rate source Figure 4.4 The dose distribution for the example of the Paris
strength 1 mGy h-1 mm-1 at 1 m. implant showing isodoses of 60 Gy, 30 Gy, 22.5 Gy, and 15 Gy.
Non-gynecological treatment systems 39

4.2.2 The Manchester System

The first widely available set of rules that could be used


to deliver a uniform dose to a target volume is often
referred to as the Manchester System, after its place of
origin and is fully described in the book Radium Dosage,
The Manchester System [9]. Excluding gynecological
treatments, three different types of brachytherapy
implant were considered: moulds, interstitial planar
implants, and volume implants. The systems used to dis-
tribute sources and calculate treatment times need to be
discussed separately for each of these cases.

MOULDS

The term mould is used to describe the situation in


which the radioactive sources are positioned external to
the patient, usually at a distance from the patient's skin
known as the treatment distance and represented by the Figure 4.6 Source arrangement for a Manchester-type mould
letter d (Figure 4.6). The treatment dose is prescribed to arrangement. Source positions are indicated by dots on the
the plane which is at distance d from the sources and the cross-section and lines on the wire positions viewed from above.
dose in this plane will be delivered with a 10% accuracy
if the rules are followed. The sources may be arranged
over the treatment area in circles or squares, circles being circle diameter to the treatment distance (d) is less than
the preferred arrangement. In both cases the target area 3. The distributions required for larger circles are given
should be bounded with radioactive sources arranged in in Table 4.4.
the required shape. Ideally, the sources should be laid in Squares will be adequately treated by the peripheral
a continuous line around the periphery, but gaps not sources only if the side of the square does not exceed
exceeding d are acceptable. twice the distance d. If the square does not meet this
For small circular treatment areas, the sources around requirement, supplementary lines of sources, parallel to
the periphery will treat the target area adequately, but the side of the square, will be needed in the interior. The
large circles may require additional sources in the inte- distance between the lines of sources must not exceed
rior. A circle may be deemed to be small if the ratio of the twice the distance d. If only one additional line of

Table 4.4 Distribution of total source activity for circular moulds

Ratio of Diameter to Treatment Distance <3 3-6 6 7.5 10

Percentage of total source activity on outer circle 100 95 80 75 70


Percentage of total source activity on a circle of
diameter half that of the outer circle - - 17 22 27
Central spot - 5 3 3 3

For small values of d


Percentage of total source activity on outer circle 100 95 90 80
Central spot - 5 10 20
40 Systems of dosimetry

sources is required, the linear source strength of the inte- Treat with a single circle 25 mm in diameter (from
rior sources should be half that of the periphery. If there Table 4.4)
are two or more additional lines, the linear strength of Area = 5 cm2
the interior sources should be two-thirds of the periph-
Total source strength x treatment time is 237
eral value.
microgray-hours at 1 m from Table 4.6.
If the target area is rectangular rather than square,
treatment times calculated for sources should be Total source strength is 25 x p x 1200 nGy h-1 at 1 m
increased. Details of this increase are given in Table 4.5. = 94.3 (mGy h-1 at 1 m.
Once the sources have been arranged and the total
source strengths used are known, the treatment time can
be calculated by looking up, in Table 4.6, the total prod-
uct of total source strength and treatment time for the INTERSTITIAL PLANAR IMPLANTS
area in use and the treatment distance. Table 4.6 gives
The interstitial rules are based on those for moulds, but
values necessary to deliver a dose of 1 Gy to the treat-
simplified to allow for the technical difficulties of
ment plane, and the value looked up should be adjusted
implanting the sources into the patient's tissue. The
proportionately for the dose actually prescribed. The
implant can be effected most easily using the square or
treatment time may then be calculated as follows:
rectangular arrangement described for moulds. Parallel
table value for total source strength x lines of sources are implanted through the center of the
treatment time
Treatment time for n Gy = n x volume and across the ends of the target volume. The
total source strength used
simplified distribution rules are given in Table 4.7. The
The dosage table is based on the original Manchester treatment time for a treatment volume 10 mm thick may
data, updated to allow for current values of the calcula- be obtained from Table 4.6 using a treatment distance of
tion parameters [10,11] and converted into SI units. 5 mm.
The target volume extends for 5 mm either side of the
EXAMPLE plane containing the wires and is thus 10 mm thick.
If it is desired to sandwich the target volume between
A circular area is to be treated to a dose of 30 Gy with
two parallel planes, the sources may be arranged in the
source of strength 1200 nGy h-1 mm-1 at 1 m. The treat-
same manner as for a single plane and the product of
ment distance is 10 mm.
total source activity and treatment is again obtained for
a treatment distance of 5 mm. The treatment time is
then increased by the factors given in Table 4.8, which
Table 4.5 Percentage increase to square implant treatment
are dependent upon the separation of the two planes.
times for rectangular implants

Ratio of side to base for rectangle 2:1 3:1 4:1


Percentage to increase treatment time 5 9 12 Table 4.7 Distribution of total source activity between
periphery and interior for planar implants

Table 4.6 Dose table for area planned according to the


Manchester System interior

0-25 67 33
25-100 50 50
>100 33 67
0 23 92 207 368
5 124 237 385 572
8 159 297 463 661
10 182 335 506 714 Table 4.8 Factor by which treatment times for two-plane
15 234 423 610 838 implants calculated for 5 mm treatment distance (e.g. from
20 285 496 704 947 Table 4.6, column 2) must be increased for plane separations
30 379 615 883 1150 greater than 10mm
40 466 722 1041 1339
50 545 829 1177 1514
60 619 932 1301 1686
80 758 1473 1520 1981
100 893 1327 1730 2235 10 1.0
15 1.25
Total air kerma source strength is expressed in mGy h-1 at 1 m and 20 1.40
treatment time is in hours. The table gives the product of total source 25 1.50
strength used and treatment time to deliver a dose of one Gy.
Non-gynecological treatment systems 41

The dose will be low in the plane halfway between the 4.2.3 The Quimby System
source planes for separations which exceed 20 mm.
It is often impractical in an afterloaded implant to This system was developed by Edith Quimby from work
have two rows of sources perpendicular to the principal she originally carried out in the 1930s [12]. The system
implanted direction. If it is not possible to cross the ends is essentially an adaptation of the Manchester System
of the implant, the implanted area may be considered to and is described in her later works [3,4].
be decreased by 10% for each uncrossed end. The lines of The Manchester System made severe demands upon
implanted sources then extend 10% of their length the radium stocks available in the USA. In general, the
beyond the ends of the target volume for each uncrossed activities were higher than those which could be obtained
end. in the UK and the range of available activities was smaller.
This made it difficult for oncologists to fulfil the require-
VOLUME IMPLANTS ments of the Manchester System for sources in the inte-
Volumes may be considered to be spherical, cylindrical, rior of the implants to have a lower linear source strength
or cuboid. Sources must be distributed throughout the than those in the periphery. It was also difficult to achieve
volume in accordance with the rules given in Table 4.9. the required spacing of the sources within the implant
In general, volumes are considered to consist of an outer without substantially changing the proportions of activ-
shell and an inner core. Within the shells and cores the ity that the Manchester System assigned to the periphery
source activity should be distributed as evenly as possi- and interior of the implant.
ble in compliance with the distribution rules, and gaps The Quimby System is based on relaxing the
between sources should ideally be less than 15 mm. Manchester System distribution rules so that uniform
The treatment times can then be determined from the linear source strength sources may be used and the activ-
volume dosage in Table 4.10 in a manner analogous to ity is distributed uniformly throughout the treatment
that for the moulds and planar implants. volume. The homogeneity of dose within the treated vol-
Again, as for planar implants, it may well be impossi- ume is not as good as that achieved by the Manchester
ble to afterload sources which are positioned perpendic- System, but the inhomogeneity was considered to be
ularly to the main direction of implantation, and acceptable in clinical practice.
cylindrical volumes should be reduced by 7.5% for each Among the possibilities that Quimby considered were:
uncrossed end. 1. Using uniform-strength needles throughout the
target volume, and achieving the desired proportions
of activity on the periphery and interior of the
implant by increasing the source separations within
Table 4.9 Distribution of source activity for volume implants
the implant beyond that allowed by the Manchester
planned in accordance with the Manchester rules
System.
2. Using uniform-strength needles throughout and
maintaining the source separations recommended by
Sphere Shell: 6 parts Core: 2 parts the Manchester System and thus altering the
Cylinder Belt: 4 parts Core: 2 parts Each end: 1 part proportions of activity allocated to the interior and
Cuboid Each side: 1 part Core: 2 parts Each end: 1 part
periphery of the implant.
Gaps between the needles should not exceed 10-15 mm.
Planar implant tables based on the Quimby system,
with the sources spread uniformly across the target, have
Table 4.10 Dose table for volumes planned according to the
been calculated as for the Manchester System, and a sam-
Quimby and Manchester systems
ple set of data (Table 4.11) is included here, based on the
work of Godden [13] and converted to SI units, in accor-
dance with the recommendations of the BIR/IPSM
Working Party report. The tables are for the number of
5 78 152 mGy total source strength multiplied by treatment time in
10 123 244 hours required to deliver a dose of 1 Gy to the target area.
20 195 335
The source strength is specified in mGy h-1 at 1 m. These
40 310 472
80 491 663
tables are analogous to the Manchester System tables,
100 570 762 which were originally published in the units of milligram-
125 662 853 hours of radium required to deliver a dose of 1000 R, but
150 747 952 have been corrected to the currently recommended SI
units and current values of calculation parameters.
Total air kerma source strength is expressed in mGy h-1 at 1 m and
treatment time is in hours. The table gives the product of total source The Quimby System deals with uncrossed ends in the
strength used and treatment time to deliver a dose of 1 Gy for sources same manner as the Manchester System, reducing the
with a filtration equivalent to 0.5 mm of platinum. treated area by 10% for each end of the target volume not
42 Systems of dosimetry

Table 4.11 Sample dosage table for implanted areas planned Initially, the total implanted activity in millicuries was
according to the Quimby System simply taken to be five times the average dimension in
centimeters, the average dimension simply being the
Square applicators
mean of the length, width, and thickness of the target
volume. The factor 5 was based on previous clinical
experience.
10 35 107 224 381 It was expected that this system would result in a
20 61 143 263 434 patient dose that varied inversely as the sixth root of the
50 190 309 457 652 volume. Clinically, it is well known that small volumes
can tolerate higher doses than large volumes, so this slow
Rectangular applicators reduction of treatment dose was thought to correspond
well to clinical need. In practice, it was found that the
dose varied more rapidly than the sixth root of the vol-
ume and this was attributed to absorption of the low-
10x15 39 112 227 385 energy iodine-125 emissions by tissue. Tissue scatter and
40x60 218 324 475 666 absorption are not usually clinically significant for the
60x90 434 553 720 944 radionuclides used in the classical dose systems. The
average dimension method was thus modified to
Circular applicators
increase the amount of activity used in larger volume
implants.
The factor 5 was replaced as follows:
10 34 104 215 378 factor = 5 average dimension < 2.4 cm
30 79 167 305 462 factor = 3.87 (average 2.4 < average dimension < 3.24
60 228 345 519 699 dimension + 1.0)1293
Total air kerma source strength is expressed in mGy h-1 at 1 m and factor = 2.76 (average average dimension > 3.23
treatment time is in hours. The table gives the product of total source dimension + 1.0)1581
strength used and treatment time to deliver a dose of 1 Gy for sources
with a filtration equivalent to 0.5 mm of platinum.
PRACTICAL USE

To simplify the calculations of activity required for an


bounded by sources. The sources should thus extend well implant, a nomogram was produced which allowed the
beyond the boundary of the target volume if it is not pos- brachytherapist to calculate the necessary number of
sible to place sources across the ends of the target volume. seeds and seed strength for a particular volume. The
When considering volume implants, Quimby exam- brachytherapist measures the dimensions of the volume
ined the effects of distributing the source activity uni- to be implanted in the coronal, sagittal, and transverse
formly throughout the volume. She published tables of planes and calculates the average dimension. A nomo-
total source strength multiplied by treatment time to gram is then used to determine the number of seeds
deliver a treatment dose to the periphery of the target which should be implanted for the seed activity avail-
volume for volume implants, assuming the activity is able. The activity is then spread uniformly throughout
uniformly distributed. Some data are reproduced in the volume in a three-dimensional matrix. Practical con-
Table 4.10, corrected for modern units. The quantity siderations usually constrain the separation of the
total source strength multiplied by treatment time differs columns of seeds to 'round' number separations, e.g.,
substantially from the Manchester System because these 10 mm, 15 mm, etc., and the nomogram will indicate the
tables deliver a minimum treatment dose rather than an most appropriate seed spacing within the column.
average dose to a plane. Modern practice, although based on the above general
principles, dispenses with nomograms for prostatic can-
cer and is computer based. The seeds are positioned in
4.2.4 Modern seed implantation, average
the prostate under ultrasound guidance using a tem-
dimension method
plate. The use of the template restricts the seed positions;
it usually has holes for placing columns of seeds every 5
BASIC PRINCIPLES
mm. Typical implant spacing is 10 mm. The seeds must
This method is usually employed to deliver a required be positioned out to the edges of the treatment for a sat-
dose to a small-volume permanent implant afterloaded isfactory implant. The expected seed position data are
with iodine-125 seeds. A substantial part of the early entered into a treatment planning computer and source
work was done at the Memorial Sloan-Kettering Cancer activity is calculated to deliver the prescribed dose to the
Center, New York, and was based on clinical experience isodose which enclosed the target volume. Many com-
with prostatic cancer [14]. puter programs used the data of Krishnaswamy [15] for
Non-gynecological treatment systems 43

this purpose. Recommendations for calculating the dose adhering strictly to a system, the Manchester or Paris
distribution around iodine-125 seeds have been pub- rules on source length will provide satisfactory guide-
lished by the American Association of Physicists in lines.
Medicine (AAPM) brachytherapy working group [16]. It is worth noting that there is a small amount of dis-
These are the best current sources of data. The matched agreement between the Paris and Manchester systems
peripheral dose for implants, that is, the dose that about the distance beyond the target volume which the
encloses a volume of the dimensions to be treated, is sources should extend. The Paris System recommends
normally in the range 100 to more than 200 Gy. The dose that the source length is 40% greater than the target vol-
within the target volume will be considerably higher ume length, whereas the Manchester System recom-
than this. Further discussion of the dose distribution and mends the source lengths are increased an additional
optimization techniques are discussed by Yang et al. [17]. 10% of the volume length for each uncrossed end, i.e.,
20% of the target volume length if the sources are
implanted in one direction only.
4.2.5 Other dosimetric methods
Consideration of the above leads to the conclusion
that it is impossible to carry out any sort of brachyther-
THE 'NO SYSTEM' METHOD
apy work without following some basic guidelines or
It is possible to implant a patient without following any rules for source distribution and choice of prescription
rigid dosimetric system such as those described previ- isodose, even if these are not quite so formally set out as
ously. The brachytherapist may position the radioactive for the systems described above. It is appropriate to
sources to cover the target volume as he or she thinks fit. emphasize at this point that systems should not be
The source catheter positions may then be calculated mixed. For example, one should never distribute the
using orthogonal radiographs, isocentric films, or any source activity in accordance with the Paris or Quimby
other appropriate method available. The dose distribu- systems and then use the Manchester System tables to
tion is then calculated either by hand, using published determine the treatment time. If one chooses to use a
data for the sources in use, or, more usually, with the aid particular system, then the rules for that particular sys-
of a computer program. Suitable programs are available tem should be scrupulously followed. If the brachyther-
in most radiotherapy departments. The brachytherapist apist chooses not to use a system, then particular
then prescribes the treatment dose to the isodose that attention must be paid to the choice of source separa-
most appropriately covers the target volume. tion, prescription isodose, and length of treatment
There are considerable dangers in this system, which sources with respect to the treatment volume.
may cause the unwary practitioner to give a considerable
overdose to parts of the treatment volume. There is a
DOSE-VOLUME HISTOGRAMS
very steep dose gradient around each wire, principally
because of the operation of the inverse square law from Dose-volume histograms are, strictly speaking, not a
every element of every source. It is essential that the dosimetric system, but a method of examining and ana-
sources are not so widely separated that, if the dose is lyzing the implant. The analysis may be used to change
prescribed to an isodose that envelops all the wires, the the treatment prescription and for that reason dose-
inevitable high dose region around each source is large volume histograms are discussed in this chapter.
enough to cause necrosis. The guidelines for maximum The simplest form of dose-volume histogram is
source separations used in the Paris System may be taken obtained by calculating the dose at every point on a
as a useful indicator. It is also essential that the matrix which covers the dose volume and sorting the
brachytherapist makes a carefully considered choice of points into dose bins. Each point represents the dose in a
prescription isodose. An isodose which is at a large dis- volume element of the matrix and thus counting the
tance from the sources may appear to be a good choice points which fall into each dose band allows the volume
in that it covers the required treatment volume, but if the receiving a minimum of any particular dose to be calcu-
dose is prescribed at a large distance from the sources, lated. This will allow the volume receiving a high dose,
necrosis may occur in the vicinity of the sources. Again, for example twice the prescribed dose, to be calculated
the Paris System guidelines may be used to determine the and may give some information about possible dangers
maximum treatment thickness permissible with any par- of necrosis. There is little useful information to be
ticular source separation. obtained about uniformity of the implant.
The dose delivered by brachytherapy sources falls off An alternative approach, known as 'natural' volume-
toward the physical end of the source and for that reason dose histograms, was developed by Anderson [18] in
the sources must always extend beyond the end of the 1986. The basic aim of their work was to remove one
target volume or, alternatively, the quantity of source large source of dose variation within the implant, the
activity at the boundary of the target volume must be inverse square law, from the dose-volume histogram in
increased by 'crossing the ends' as per the Manchester order that the effect of other contributors to non-
System. Once again, even if the brachytherapist is not uniformity to the implant, i.e., poor source positions,
44 Systems of dosimetry

could be more clearly seen. They showed that for a sin- 43 INTRACAVITARY THERAPY FOR
gle source plotting the volume in dose bins which varied GYNECOLOGICAL CANCER
with dose rate to the power 3/2 would result in every
bin containing the same number of dose points or vol-
4.3.1 Cervical cancer
ume elements. However, for multisource implants, a
peak in the graph is obtained at a dose rate approxi-
THE MANCHESTER SYSTEM
mately equal to the average value at points midway
between adjacent sources. A typical multisource implant This system was initially developed for radium tubes, but
graph is shown in Figure 4.7. The more uniform the was easily adapted to different afterloading systems. The
dose rate within the implant, the higher and sharper the Manchester System [20] specifies the spatial distribution
peak will be. Anderson suggests that the dose rate at of sources in specially designed applicators and their rel-
which the prescribed dose is delivered should be close to ative activity and defines reference points at which the
the dose rate at which the histogram peak occurs. If the dose is calculated. The applicators consist of a central
treatment dose rate is substantially lower than the peak tube inserted into the uterus and locating on the cervix
dose rate, undesirably large doses may be given within by means of a flange, and a pair of ovoids, which nor-
the implant, with the accompanying risk of necrosis, mally sit in the vaginal fornices. To cope with individual
whereas if the treatment dose rate is significantly higher variations in patient anatomy, different combinations of
than the peak dose rate, a large volume outside the tar- central tube length and ovoid size are used and the sepa-
get region may be receiving a dose close to the treat- ration between the ovoids can also be adjusted. In the
ment dose. extreme case of the narrow vagina, it may be necessary to
In practice, it has been found that, for implants car- insert the ovoids in tandem along the vagina.
ried out following the Paris System rules, the peak of the In the Manchester System, the dose is specified at
volume-dose histogram corresponds closely to the aver- point A, which is defined as 2 cm superior to the mucous
age basal dose rate [19]. Thus, the position of the peak membrane of the lateral fornix (which, for practical pur-
on the natural dose-volume histogram could be used as poses, is level with the external os) in the plane of the
a guide to the value of the basal dose rate. For implants uterine tube and 2 cm lateral to the center of the uterine
which follow the Manchester System, the treatment dose canal, as shown in Figure 4.8. The dose at point A is rep-
rate has been found to be approximately 60-90% of the resentative of the dose throughout much of the malig-
peak dose rate. Because the Manchester System is based nant tissue. In addition, point B is defined 5 cm laterally
on delivering an average dose to a particular treatment to midline at the same level as the A points and repre-
plane, it is not surprising that the peak of the histogram sents the dose to the pelvic wall. The dose at point B is
does not reliably indicate the Manchester treatment dose approximately 20-25% of the dose at point A and is of
rate. importance when calculating the total dose when
The position of the peak in the natural dose-volume brachytherapy is combined with external-beam irradia-
histogram may be helpful in choosing a treatment iso- tion.
dose, particularly for those implants that were based on There were two reasons for the choice of point A as the
the Paris System, even if the final source distribution dose specification point: treatment was thought to be
does not comply strictly with the Paris rules. The limited by the tissue tolerance of the paracervical trian-
brachytherapist should be wary of routinely prescribing gle, and the dose rate at this point is not too sensitive to
to 85% of the peak dose rate without first checking that small variations in applicator position. When loaded
this will not lead to a significant overdose in any part of according to the rules shown in Figure 4.9, the different
the implant. combinations of central tube and ovoid deliver approxi-
mately the same dose rate to the A points (as shown in
Table 4.12), and ensure a suitable ratio between the vagi-
nal and intrauterine contributions to the dose at point A,
with the ovoids contributing no more than one-third of
the dose. Although point A was thought to be anatomi-
cally comparable between patients, it is in fact a point
which is related to the geometry of the sources and not
to patient anatomy. Consequently, for a non-ideal inser-
tion in which the uterine canal is rotated, the A points
also rotate as shown in Figure 4.10. A typical isodose dis-
tribution is shown in Figure 4.11.
Applicators that reproduce the traditional Manchester
Arbitrary units on scale of (dose rate) -3/2 geometry are available for manual and low and high dose
Figure 4.7 'Natural' dose-volume histogram for seven evenly rate remote afterloading systems. In order to minimize
spaced wires. the risk of sources sticking in the afterloading
Intracavitary therapy for gynecological cancer 45

Figure 4.8 Position of A and B points for an ideal insertion, (a) Lateral view, (b) anterior-oblique view.

Figure 4.9 Manchester System: loading patterns for uterine tubes and avoids.
46 Systems of dosimetry

Figure 4.10 Position of A and B points for a non-ideal


insertion.

applicators, they usually have a less flexible central tube Figure 4.11 A typical isodose distribution for treatment of
and the geometry of the applicators is often more rigid. carcinoma of the cervix according to the Manchester System.
Some configurations, e.g., ovoids in tandem, which were
possible with the traditional Manchester applicators may
not be possible with all afterloading systems, although the ovoids. The packing also eliminates movement of the
alternative applicators may be supplied. applicators during treatment.
In the traditional system, for treatment using Strict adherence to the Manchester System means that
brachytherapy alone the dose prescribed to point A at the dose rate and hence the insertion time are taken from
conventional low dose rates is 74 Gy in 140 h split into the standard tables for an ideal insertion. Many oncolo-
two fractions with approximately 1 week between frac- gists, however, prefer to calculate the dose rate, and
tions. (Please refer to Chapter 25 for further details of hence the insertion time, at point A by computer. The
cervix treatment.) Manchester applicators do not incor- use of computer planning and afterloading systems
porate rectal shielding. The dose to this critical structure allows standard dose distributions to be modified if
is minimized by careful positioning of the applicators required by adjusting the source arrangement or dwell
and by careful packing of at least 1.5 cm of gauze behind times of individual source trains. Caution must be

Table 4.12 Dose rates at point A for standard Manchester loadings

6-cm uterine tube 6, 4, 4 units 34.4


4-cm uterine tube 6,4 units 34.2
2-cm uterine tube 8 units 27.3
Large ovoids 9 units 1 -cm spacer 18.3
Medium ovoids 8 units 1 -cm spacer 18.8
Small ovoids 7 units 1 -cm spacer 18.9
Large ovoids 9 units Washer 18.9
Medium ovoids 8 units Washer 19.0
Small ovoids 7 units Washer 19.0
Large ovoids 9 units In tandem 14.6
Medium ovoids 8 units In tandem 14.9
Small ovoids 7 units In tandem 14.8

The unit of source activity is 18 u.Gy h-1 (2.5 mg radium equivalent).


References 47

exercised when departing from the standard conditions. THE STOCKHOLM SYSTEM
In particular, the radiobiological effect of different dose
rates must be taken into account. The traditional technique involved packing the uterus
with capsules containing radium sources known as
Isodose distributions produced by computer can be
used to establish afterloading source distributions which Heyman capsules. The uterus was stretched as these were
give rise to dose distributions comparable to those pro- inserted until it was full. At the end of treatment, the
duced by conventional radium systems. A remote after- carefully numbered sources had to be removed in reverse
loading implementation of the Manchester System has order from that in which they had been inserted. The
been described by Wilkinson et al. [21]. dose specification point is 15 mm from the surface of the
most lateral applicator. Lundberg et al. [25] describe an
OTHER DOSIMETRY SYSTEMS FOR CERVICAL
adaptation of this technique for remote afterloading.
CANCER

The use of Fletcher-type applicators (where shielding is 433 Vaginal irradiation


used in the colpostats to reduce the bladder and rectal
dose) with afterloading systems has been considered by Vaginal applicators include cylinders of different diame-
Marbach et al. [22]. Fletcher applicators require the ters, ovoids, and custom-made moulages, which may be
placement of two sources in the vagina in a manner sim- used to deliver a surface dose (typically 60 Gy) for treat-
ilar to that of the Manchester System, but the source ment given by brachytherapy alone.
applicators are of a different shape from Manchester
ovoids. Shielding is placed in the upper and lower poles
4.4 PRACTICAL CONSIDERATIONS
of the vaginal applicators to provide rectal and bladder
shielding. The original system did not permit afterload-
ing but there are now modified designs available for The different dosimetry systems all have slightly differ-
afterloading machines. ent philosophies and it is important not to attempt to
Isodose distributions can also be used to design load- change from one system to another without giving due
ing patterns for different types of applicator and tech- consideration to the consequences to the patient in such
nique, effectively tailoring the treatment volume as an event.
defined in the ICRU Report 38 [23] to the requirements The Manchester mould and interstitial system
of the brachytherapist. Excellent descriptions of the achieves a high degree of uniformity to a particular
Gustave-Roussy technique and the Creteil System are treatment plane if the rules are carefully followed, but
given by Pierquin et al. [7]. the required source positions may sometimes be difficult
The majority of techniques for brachytherapy of the to achieve in an afterloading system. The source posi-
cervix give rise to a pear-shaped irradiation volume. tioning is simpler for the Paris and Quimby systems, but
Some systems, e.g., the Newcastle System [24], are the dose specification is different.
designed to give a more cylindrical distribution which Whichever system is used, it is essential for accurate
can be matched more easily to external-beam irradiation. dosimetry that the source positions of any implant are
This is achieved by replacing the two ovoids with a single, known precisely. They can be obtained from orthogonal
cylindrical, vaginal applicator. It is possible to incorpo- or isocentric radiographs, direct measurement from the
rate rectal shielding into the cylindrical applicator. The patient or a template, shift films or possibly computed
Newcastle System continues to use the Manchester defin- tomography. Poor reconstruction of source positions
ition of points A and B for dose specification. will inevitably lead to poor accuracy of dosimetry.

4.3.2 Carcinoma of the body of the uterus REFERENCES

THE MANCHESTER SYSTEM


1. Coliez, R. (1923) Les bases physiques de I'irradiation du
Traditionally, a 1 cm diameter uterine tube was used in cancer de col uterin par la CurietherapieJ. Radio!., 7,
conjunction with ovoids positioned in the vaginal for- 201.
nices, the applicators again being loaded with radium. In 2. Patterson, R. and Parker, H.M. (1934) A dosage system for
the absence of a special-purpose afterloading applicator, gamma ray therapy. Br.J. Radiol., 7, 592.
a Manchester-type cervical applicator set can be used 3. Quimby, E. (1944) Dosage tables for linear radium
provided that it is possible to obtain the length (up to 12 sources. Radiology, 43, 572-7.
cm in extreme cases) of uterine tube required. The load- 4. Quimby, E. and Castro, V. (1953) Calculation of dosage in
ing patterns of the uterine tube and the ovoids differ interstitial radium therapy. Am. J. Roentgenol., 70(5),
from treatment of the cervix, with a higher proportion of 739-9.
the dose being delivered by the uterine source train. 5. Pierquin, B. and Dutreix, A. (1966) Pour une nouvelle
48 Systems of dosimetry

methodologie en curitherapie; le Systeme de Paris. Endo 18. Anderson, L. (1986) A natural volume-dose histogram for
et plesio-radiotherapie avec preparation curietherapie brachytherapy. Med. Phys. 13(1), 898-903.
non-radioactive. Ann. Radiol., 9,757. 19. Langmack, K.A. and Thomas, S.J. (1995), The application
6. Pierquin, B., Dutreix, A., Paine, C.H.et al. (1978) The Paris of dose-volume histograms to the Paris and Manchester
system in interstitial radiation therapy. Acta Radiol. Systems of brachytherapy dosimetry. Br.J. Radiol., 68,
Oncol.,17,33. 42-8.
7. Pierquin, B., Wilson, J. F. and Chassagne, D. (1987) Modern 20. Tod, M. and Meredith, W.J. (1953) Treatment of Cancer of
Brachytherapy, New York, Masson. the Cervix Uteri - a Revised 'Manchester Method'. Br. J.
8. Aird, E.G.A., Jones, C.H.Joslin, CAR et al. (1993) Radiol., 26,252.
Recommendations for Brachytherapy Dosimetry. London, 21. Wilkinson, J.M., Moore, C.J., Notley, H.M. and Hunter, R.D.
British Institute of Radiology. (1983) The use of Selectron afterloading equipment to
9. Meredith, W.J. (ed.) (1949) Radium Dosage, The Manchester simulate and extend the Manchester System for
System. Baltimore, Williams and Wi I kins. intracavitary therapy of the cervix uteri. Br.J. Radiol., 56,
10. Gibbs, R.and MasseyJ.B. (1980) Radium dosage: SI units 409-14.
and the Manchester system. Br.J. Radiol., 53,1100-1. 22. Marbach, J.R., Stafford, P.M., Delclos, L. and Almond, P.R.
11. MasseyJ.B., Pointon, R.C.S. and Wilkinson,]. (1985)The (1984) A dosimetric comparison of the manually loaded
Manchester system and the BCRU recommendations for and Selectron remotely loaded Fletcher-Suit-Delclos utero-
brachytherapy source specifications. Br. J. Radiol., 58, vaginalapplicators. In Brachytherapy 1984, Proceedings
911-12. of the 3rd International Selectron Users Meeting 1984,
12. Quimby, E. (1932) Grouping of radium tubes in packs or ed. R.F. Mould. Veenendaal, Netherlands, Nucletron BV,
plaques to produce the desired distribution of radiation. 255-65.
Am.J. Roentgenol., 27(1), 18-39. 23. International Commission on Radiological Units and
13. Godden, T. J. (1988) Physical Aspects of Brachytherapy. Measurements (1985) Doseand Volume Specification for
Bristol and Philadephia, Adam Hilger. Reporting Intra-cavitary Therapy in Gynaecology, ICRU
14. Anderson, LL, Kuan, H.M. and Ding, I. (1981) Clinical Report 38. Bethesda, MD, ICRU.
dosimetry with 125I. In Modern Interstitial and 24. Dawes, P.J.D.K., Roberts, J.T., Dean, E.M., Lambert, G.D.
Intracavitary Radiation Cancer Management, 3rd edn., ed. and Locks, S. (1988) The treatment of cancer of the uterine
F.W. George. New York, Masson, 9-16. cervix using the Newcastle Afterloading System. In
15. Krishnaswamy, V. (1978) Dose distribution around an Brachytherapy 2, Proceedings of the 5th International
1-125 seed source in tissue. Radiology, 126(2), 489-91. Selectron Users Meeting 1988, ed. R.F. Mould. Veenendaal,
16. Nath, R., Anderson, LL, Luxton, d.et al. (1995) Dosimetry Netherlands, Nucletron BV, 235-9.
of interstitial brachytherapy sources: recommendations 25. Lundberg, L.M., Mattsson, 0. and Ragnhult, I. (1988)
of the AAPM Radiation Therapy Committee Task Group Remote afterloading of the uterine cavity using a
No. 43. Med. Phys., 22(2), 209-34. microSelectron LDRunit. In Brachytherapy2, Proceedings
17. Yang, G., Reinstein, L.E., Pai, S. and Zhigang, X. (1998) A of the 5th International Selectron Users Meeting 1988,
new genetic algorithm technique in optimisation of ed. R.F. Mould. Veenendaal, Netherlands, Nucletron BV,
permanent 125 prostate implants. Med. Phys., 25(12), 223.
2308-15.
5
Computers in brachytherapy dosimetry

ROBERT VAN DERLAARSE AND ROBERT W. LUTHMANN

5.1 INTRODUCTION utilizing computerized tomography (CT) and magnetic


resonance imaging (MRI) images, (iv) optimization of
dose distribution to the target volume, (v) evaluation of
Historically, brachytherapy treatment planning involved dose distribution using dose-volume histograms, and
the use of systems and lookup tables that allowed an (vi) combination of external-beam and brachytherapy
empirical approach toward source placement and dose distributions.
calculations [1-4]. With the introduction of treatment
planning computers came the ability to display isodose
distributions around an implant and to analyze an 5.2 FORMALISMS FOR DOSE CALCULATION
implant not only by visual evaluation of two- AROUND A SOURCE
dimensional and three-dimensional dose distributions,
but also by dose-volume histograms.
Computer-assisted dose calculations around a
Compared to a conventional low dose-rate (LDR)
brachytherapy implant are currently based upon two
treatment, high dose-rate (HDR) brachytherapy offers
formalisms: the traditional formalism [5,6] and the
two additional degrees of freedom once the catheters or
American Association of Physicists in Medicine (AAPM)
applicator have been placed: source position and dwell
Task Group 43 (TG43) formalism [7]. Both formalisms
time. By manipulating these two parameters, one can,
determine the dose to a point in medium from a single
either interactively or by computer methods, optimize
source. Basically, the AAPM Task Group 43 formalism
the dose distribution around the implant.
combines several traditional dose calculation quantities
Computerized optimization algorithms have been
into new ones, as discussed below.
developed that explicitly define the desired target dose
Using the traditional formalism, the dose rate at a
distribution and then calculate the 'optimal' dwell times
point with coordinates (r,q), Dr(r,q), can be expressed as:
and source positions required to obtain this distribution.
Optimized HDR brachytherapy is a highly conformal D,(r,Q) =Aa (U/^/pr* [G(r,e)/G(r0,00)] T(r)F(r,Q) (5.1)
type of cancer therapy.
where:
Current developments in the use of computers as
applied to brachytherapy include (i) methods for dose Aa = apparent activity in mCi.
calculation around sources, (ii) methods for source (r,)x, = exposure rate constant [R h-1mCi-1cm2]:
localization, (iii) three-dimensional visualization of for medium and low energy isotopes like
target volume, organs at risk, and dose distribution iridium-192, the value of (Gd)x depends on
50 Computers in brachytherapy dosimetry

the spectral distribution of the attenuation For the source strength specification of sources, the ref-
of radiation filtered through the erence air kerma rate (Kk) or the reference exposure rate
encapsulation of the source. (Xk) is usually given:
/ = exposure to air kerma conversion factor
[cGy R-1] (0.8764 cGy/R-1 in air). Kk = reference air kerma rate (cGy h-1 m2), the kerma
(m/p)tissue/air = ratio of the mass energy absorption rate in air at 1 m, disregarding air attenuation
coefficient of tissue to that of air, where and room scatter.
Xk = reference exposure rate (R h-1 m 2 ), the exposure
(m/p)tissue/air=/(m/P)air,

G(r,q) = a geometry factor for the dose in point (r,q) rate in air at 1 m, disregarding air attenuation
accounting for the distribution of the and room scatter.
radioactive material. For a point source, In the case of a point source:
G(r,q) = 1/r2. For a line source with active
length I, G(r,q) = b/(L r sin q) with b the
angle subtended by the active length L at
point (r,9) (Figure 5.1). The factor 104 accounts for K k and Xk being defined at
(r0,q0) = the reference point that lies on the 1 m and (Fg)x at 1 cm.
transverse axis of the source (q0 = 90) at The AAPM Task Group 43 [7] focuses on the dosime-
1 cm distance from the source. Thus, for a try of iridium-192, iodine-125, and palladium-103
point source, G(r0,q0) = 1 and, for a line seeds. However, the TG43 formalism is also applied to
source, G(r0,q0) = b/I. HDR and pulsed dose-rate (PDR) stepping sources. It
T(r) = tissue attenuation function (e.g., the recommends obtaining the dose rate in a point with
Meisberger function [8]). This function coordinates (r,q) as follows:
accounts for absorption and scatter in
tissue along the transverse axis. For
medium or low energy isotopes, T(r) also
Where:
depends on the filtering of the radiation
through the source encapsulation. Sk = air kerma strength (cGy h-1 cm2): the air kerma
F(r,q) = the angular anisotropy function that rate on the transversal axis at 1 cm distance
accounts for the absorption and scattering from the source, based on a measurement at a
in the medium and the source large distance and converted to 1 cm distance by
encapsulation. The function value on the considering the source as a point source. Thus,
transverse axis, F(r,90), is defined as 1 for this quantity is related to the reference air kerma
all r values. rate Kk(cGy h-1 m2) by the inverse square law:
S k =10 4 K k .
A = specific dose rate constant: the dose rate in
tissue per unit air kerma strength at 1 cm
distance from the source. This constant is not
based upon an idealized point source, but,
instead, is dependent upon the physical
configuration of the source.
g(r) = radial dose function: this function accounts for
absorption and scatter along the transverse axis.
Note that g(r) = 1 for r = r0 (= 1 cm).

For a point source, equation (5.3) can be obtained from


equation (5.1) by combining several traditional dose cal-
culation quantities into new ones:

Figure 5.1 Illustration of the geometry used in the dose Note that Sk is the air kerma rate at 1 cm on the trans-
calculation around a line source. L = active length of line source; verse axis of the source as if the source is a point source.
P( r o>q 0 ) - reference point on the transverse axis of the source; SkA is the real dose rate in tissue at 1 cm on the trans-
P(r,q) = point to calculate the dose at; (3 = angle subtended by verse axis of the source. From this follows that A is also a
the active length L. function of the active length of the source.
Calculating of dose by computer 51

53 CALCULATING OF DOSE BY COMPUTER subtended by the active length L at point (r,q). The mod-
eling as a line source is of importance when calculating
dose rates at distances shorter than 2 L. If HDR stepping
To calculate dose to points around an HDR source, sources with an active length of 3 mm or more are not
either equation (5.1) or (5.3), or a mixture of both, can modelled as a line source, doses calculated at distances
be used by computer algorithms. The orientation of the shorter than 6 mm are less accurate [9-11].
source in free space must be known in order to apply the
geometry factor G(r,q) and the anisotropy factor F(r,q).
Localization techniques that supply this information are 53.4 Dose anisotropy function, F(r,q)
an essential part of any brachytherapy treatment plan-
ning system and are discussed in section 5.4. The dose anisotropy function, F(r,q), accounts for the
In this section, the different dose calculation parame- anisotropic behavior of the dose distribution around the
ters are discussed, with emphasis on sources used in source, due to the self-absorption in the active material
afterloading. and the attenuation in the encapsulation of the source.
The value of the anisotropy function at the distance r
53.1 Source strength from the source along the transversal axis, F(r, 90), is
defined as 1.0. The anisotropy correction can be handled
Typically, the source strength is derived from the mea- in several ways, depending upon the radiation spectrum
sured air kerma rate at 1 m, a distance much larger than of the isotope and the physical form and encapsulation
1 cm, at which distance a source is practically a point of the source. Measured F(r,q) values, stored in tables,
source. The reference air kerma rate kk, defined at 1 m, is are often fitted to functions that are used in computer
obtained directly from this measurement. The air kerma algorithms.
For sources emitting high energy radiation, such as a
strength Sk is derived from Kk using Sk = 104 Kk for both a
point source and a line source. Thus, Sk is the air kerma cesium-137 source, the anisotropy correction for a point
rate at 1 cm on the transverse axis of the source, as if the P(r,q) can be calculated by subdividing the active mate-
source is a point source. The apparent activity (Aa) fol- rial in the source in small volume elements Da. For each
lows from Kk using equation (5.2), Aa = 104 Kk/[(Gd)xf]. element Da the path ra through the active material itself
For iridium-192 sources, Kk or Sk values should be and the path rw through the source wall are determined.
entered into the planning program instead of the derived This gives a correction factor exp [-(ma ra + mw rw ], with ma
Aa values, as there are different values published for (Gd)x. the linear attenuation coefficient for the active source
If a planning system requires the entry of apparent activ- material and |iw the linear attenuation coefficient for the
ity, then the same (Gd)x must be used when converting encapsulation material. By summing over all active vol-
measured air kerma rate to apparent activity as when cal- ume elements Da, the correction factor C(r,q) for point
culating dose values. Otherwise, a serious error in the P(r,q), is found. NowF(r,q) = C(r,q)/C(r,90).
dose given to the patient may occur. In the traditional approach of dose calculation around
radium and cesium tubes, the interval method is used.
This method divides the source in a large number of
53.2 Specific dose-rate constant (A) point sources and calculates the attenuation of the rays
from each point source by the source encapsulation
The specific dose-rate constant (A) is defined as the dose [12,13]. Thus, there is no strict separation between the
rate in tissue per unit air kerma strength at 1 cm from the geometry factor and the anisotropy factor.
source center along the transversal axis of the source. It For sources with medium or low range energies, an
depends upon the physical configuration of the source, analytical correction is not possible due to the depen-
i.e., its active length, and upon the radiation spectrum. dence of the tissue scattering and absorption on the radi-
The latter influence is due to the tissue scattering and ation spectrum. For such a source, a table with measured
absorption factor at 1 cm, T(r0), which depends on the values of F(r,0) or a function fitted to these values is
radiation spectrum. Thus, there will be different dose used. The AAPM Task Group 43 report [7] gives tabu-
rate constants for identical isotopes in sources with dif- lated values of -F(r,q) and G(r,q) for iodine-125, iridium-
ferent physical configurations. 192, and iridium-103 seeds, currently in use. Some
authors present tables which are corrected for the inverse
square law only and normalized to 1 at 1 cm distance
533 Geometry factor, 6(r,q) from the source center on the transversal axis, thus rep-
resenting F(r,q) g(r) values. The multiplication factor to
Depending on the active length of a source, either a the dose in the point (1 cm, 90) to obtain the dose in
point source or a line source should be assumed. For a point (r,0) then becomes F(r,q) g(r)/r2 [14].
point source, G(r,q) = 1/r2 and for a line source with For sources of medium range energies, such as
active length I, G(r,q) = b(I r sin 0) with (3 the angle iridium-192, there is less variation in the values of the
52 Computers in brachytherapy dosimetry

anisotropy function with distance r from the source. 5.4.1 Specification of coordinates
Therefore, the anisotropy function in some older plan-
ning systems is taken as F(q), with F(90) again defined If the three-dimensional coordinates of the sources or
as 1. It is usually implemented as F(q)/r2, with F(q) a dwell positions are known, keyboard entry of these data
table with values for 0 between 0 and 180 [15]. can be used. This, of course, is the most accurate descrip-
Accurate dose values around an HDR source with an tion of the source positions.
active length of 3.5 mm are obtained by using F(q)
G(r,q), with G(r,q) applied for a line source of 3.5 mm.
5.4.2 Localization using film imaging
These dose values are even valid for short distances up to
techniques
1 mm to the source center [9].
If the orientation of an HDR stepping source in space
If the absolute coordinates are not known, imaging
is not known, then only the inverse square law with a
localization techniques must be used. These imaging
fixed anisotropy factor, the anisotropy constant (jan, can
techniques utilize either plane radiographs taken from
be applied. The value of (jan is less than 1.
different directions, or computed tomography (CT)/
magnetic resonance imaging (MRI) images of the
53.5 Tissue attenuation factors, T(r) implant. If an afterloading technique is used, it is neces-
andg(f) sary to simulate the position of the sources or dwell posi-
tions utilizing localization markers. These X-ray markers
The tissue attenuation function, T(r), and the radial dose must be (i) easily discernible on the radiograph or
function, g(r), both account for the effects of absorption CT/MRI slice, (ii) accurately depicting the source or
and scatter in tissue along the transverse axis of the dwell position, and (iii) coded such that the user can
source. In most computer algorithms, the tissue attenua- determine which markers correspond to a given catheter
tion function is applied to represent the dose fall-off or applicator. They usually consist of a thin, braided,
along the transverse axis, due to tissue absorption and metal wire with markers of high Z metal at every cen-
scattering. The function T(r) is normally expressed as a timeter. By counting from the catheter tip, correspond-
polynomial in the form of: ing images of a given X-ray marker are easily found. The
images of these markers are called catheter describing
points as the corresponding images of two plane radio-
The parameters a; most often used are those of graphs are projections of the same point in a catheter.
Meisberger et al. [8], which are valid for the range of 1 In implants with many catheters close to one another,
cm through 8 cm. At depths beyond 8 cm, the above it is sometimes difficult to follow these X-ray markers. In
expression decreases sharply and, at those depths, T(r) is this case high Z wires can be inserted in each catheter up
usually approximated by exp(m t r). to the catheter tip. The images of these wires, starting at
A fit function with the least number of parameters is the catheter tip, are digitized from two-plane radio-
the modified Van Kleffens and Star function [16]: graphs. The localization in space of each catheter can be
reconstructed from its images on the two radiographs by
dedicated software. This technique is called catheter
For indium-192 the parameter a equals 0 and equa- image tracking. The points describing the curvature of
tion 5.8 reduces to T(r) = d(l + b r2) with 8 = 1.008 and an image are called catheter image points. Contrary to
b = 0.0012 cm-2. Equation 5.8 coincides with the the catheter describing points, there is no direct link
Meisberger relation within 0.5% for sources with between the catheter image points on the two radio-
medium and high range energies, such as iridium-192, graphs.
cesium-137, and cobalt-60. At depths beyond 8 cm, equa-
tion 5.8 decreases gradually and a separate exponential ORTHOGONAL RECONSTRUCTION METHOD
attenuation function is not needed when calculating clin-
The most widely used radiographic method for source
ical dose distributions around implants or applications.
localization is the orthogonal reconstruction method
[17]. Two-plane radiographs of the implant are taken in
a lateral and antero-posterior (AP) orientation. Either a
5.4 RECONSTRUCTION OF SOURCE
radiotherapy simulator is used or a localization box with
LOCALIZATION
cross-wires on the faces of the box is placed over the
patient (Figure 5.2). In the latter case, the beams are
In order to obtain the dose distribution around an aligned such that the X-ray images of opposing cross-
implant or application, the exact position of each source wires coincide. The advantage of this technique is that
or dwell position in space must be known. For the recon- AP and lateral radiographs are easily interpreted by the
struction of the source localizations by a treatment plan- physician. A disadvantage is, however, that sources or
ning program, different techniques are available. X-ray markers in the lateral X-ray film are often difficult
Reconstruction of source localization 53

Figure 5.2 Orthogonal reconstruction. The beam set-up is Figure 5.3 Semi-orthogonal reconstruction. The beam set-up is
obtained by calculation of the localization of the AP and lateral obtained by calculation of the localization of the AP and the
X-ray foci from the cross-wire images on the radiographs. Instead lateral X-ray foci from the size and the displacement of both
of a reconstruction jig to adjust the AP and lateral beams, a cross-wire images on the radiographs. I = center of box; P - point
radiotherapy simulator with gantry angles of 0 and 90 can be to be reconstructed.
used. I - isocenter; P = point to be reconstructed.

ISOCENTRIC RECONSTRUCTION METHOD


to distinguish, particularly in the pelvic region, due to With an isocentric X-ray unit, such as a radiotherapy
the thickness of tissue and the overlying bony structures. simulator, two images of the X-ray markers in each
catheter can be obtained on a single, large-size radio-
SEMI-ORTHOGONAL RECONSTRUCTION METHOD graph [17] (Figure 5.4). The gantry angle of the first
Truly orthogonal orientations for the AP and lateral X-ray beam is -a and of the second beam is +a, with the
film are not easily obtainable with portable X-ray units.
In the semi-orthogonal reconstruction method, a local-
ization jig with AP and lateral cross-wires is placed over
the patient and two radiographs (a lateral and AP) are
taken [18] (Figure 5.3). It is not necessary for these to
be truly orthogonal, because the set-up information
will be determined by the computer from the size and
the relative distances of the cross-wire lead marker
images on each of the two films. This method, there-
fore, accepts X-ray beams whose central axes do not
intersect and are not perpendicular to one another. The
only requirement is that the projections of the cross-
wires on the two corresponding box faces are visible on
the radiographs.
The semi-orthogonal reconstruction method has
proven to be particularly advantageous in HDR endo-
bronchial applications. Directly after insertion of the Figure 5.4 Isocentric reconstruction, a - reconstruction angle;
catheters, a portable radiographic X-ray unit can be used FID -focus to isocenter distance; IFD = isocenter to film
with the localization box to obtain the radiographs for distance; I = isocenter; P=point to be reconstructed. This method
localization of the catheters. This will shorten the time requires an isocentric X-ray unit such as a treatment simulator. A
between the insertion of the catheters and the treatment large-size film is placed under the patient. The beam set-up is
of the patient considerably, because there is no localiza- obtained by rotating the gantry over an angle of +a and -a,
tion session on a radiotherapy simulator required. with a preferably in the range of 15-30.
54 Computers in brachytherapy dosimetry

total angle (2a) between the central axes of the project-


ing beams taken as large as possible. In order to visualize
both images on this radiograph, it is essential that the
isocenter is placed in the center of the implant and that
the X-ray field is defined such that the two images on the
radiograph do not overlap.
Due to the equal angles between the left and right cen-
tral axes with respect to the normal to the radiograph,
lines between corresponding points on the left and right
image all run parallel. This aids in the determination of
individual seed or dwell positions from one image to the
other. Usually, the gantry angle of each image with
respect to the normal of the radiograph is between 15
and 30, depending on the extension of the implant and
the distance between the isocenter and the X-ray film.
Figure 5.5 Variable angle reconstruction. a=gantry angle
STEREO-SHIFT RECONSTRUCTION METHOD
beam 1; b=gantry angle beam 2; FID 1 -focus to isocenter
The set-up is similar to that of the isocentric method, distance beam 1; IFD 1 = isocenter to film distance beam 1; FID 2
but, instead of the X-ray tube rotating, it is moved later- =focus to isocenter distance beam 2; IFD 2 = isocenter to film
ally over a given distance [ 17]. This method is applicable, distance beam 2; I = isocenter. The two gantry angles a and b
for instance, with a ceiling-mounted X-ray unit where are determined such that the catheters are clearly visible on the
such a lateral movement is available. Usually, the angle image intensifier. The total angle a+b should preferably lie
between the two projecting beams is very small, typically between 60 and 120. The radiographs are made with the film
7, which makes this method very sensitive to even small in the cassette holder on top of the image intensifier.
errors in the measuring of the source images or a small
movement of the patient between the taking of the radi-
ographs. If possible, this reconstruction method should better delineate the source or X-ray marker positions, the
be avoided. target volume, and the surrounding organs. A problem
exists with imaging equipment such as image intensifiers,
VARIABLE ANGLE RECONSTRUCTION METHOD where the image may be distorted by the cushion effect
and the influence of the earth magnetic field, which will
This method reconstructs the localization of the change with the gantry angle. To minimize these effects,
catheters from two radiographs taken with a therapy the implant should be kept in the center of the image.
treatment simulator [19] (Figure 5.5). The only limita- Of course, the reconstruction methods based on two
tion is that the central axes of the projecting beams are radiographs taken at different directions can still be used
not coinciding or opposing. The reconstruction algo- by replacing the digitizer with the mouse. However, if
rithm requires that the angle, focus-isocenter distance, both digitized films can be displayed together on the
and isocenter-film distance of each radiograph are accu- monitor, an extension of the variable angle reconstruc-
rately known. The advantage of this technique is that the tion method becomes possible. By pointing with the
implant can be observed fluoroscopically at various mouse to a point on one of the digitized films, the plan-
gantry angles to define the two gantry angles that display ning program can draw the ray from the corresponding
the sources or localization dummies with the highest X-ray focus to that point. The other X-ray focus will pro-
clarity and least obstruction. It is preferred that the total ject that ray to the other film as a line over it. This line on
angle between the two projecting beams lies between 60 the second film is called the correspondence line to the
and 120. Of course, the greatest accuracy is obtained point on the first film (Figure 5.6). Thus, by moving the
when this total angle is 90. The orthogonal reconstruc- mouse over one of the digitized films to the image of an
tion method is a special case, e.g., with gantry angles 0 X-ray marker, the correspondence line moves over the
and 90. other film until it intersects the other image of this
marker. In this way the corresponding images in both
RECONSTRUCTION METHODS USING radiographs are easily found and reconstruction meth-
CORRESPONDENCE LINES ods based on catheter describing points can be used.
A digital image can be obtained by scanning a radi-
ographic film with a film scanner or, in real time, by a 5.43 Tracking of catheter images
portal imaging device mounted on the X-ray equipment.
These images are then displayed on the treatment plan- Sometimes, visually matching of X-ray markers on the
ning computer which has options to enhance them to two localization radiographs is not easily done, as in the
Reconstruction of source localization 55

orthogonal reconstruction method. In the case of after-


loaded sources or of stepping source dwell positions in a
catheter, image tracking reconstruction can still be used
[ 19]. Again, the tip of each catheter needs to be visible on
both images. Subsequent points on each image are
placed such that they describe the curvature of the
image. Each one of the two catheter images is then digi-
tized, starting with the tip, until a point beyond the last
source or dwell position is entered. The advantage of this
technique is that the points depicting the image on the
first radiograph are not corresponding to the ones on the
second radiographic image. Thus, any radio-opaque
marker (e.g., any flexible metal cable) can be used to
depict the catheter. This technique simplifies the data
entry into the planning system, but is less accurate in
Figure 5.6 Reconstruction using correspondence lines. C1 and
handling any patient shift between the taking of the two
C2 are images of the same X-ray marker in the catheter. [1] and
radiographs, as is discussed in the section on reconstruc-
[2] are the films obtained by variable angle reconstruction. They
tion accuracy below.
are digitized by a film scanner and displayed on the monitor.
Digital images from CT or MRI scanners are also used
After entering marker image C2 on film 2, the ray of focus 2 to C2
for treatment planning. Usually, a series of parallel,
is projected to film [1] as the correspondence line of C2. The
transverse slices through the treatment volume and its
intersection of this projection with the catheter image on film 7
surroundings is obtained. The digital images are dis-
gives the point C1. The intersection of the rays focus 2-C2 and
played on the monitor of the treatment planning com-
focus 1-C1 gives the reconstructed localization of the marker in
puter, which has options to enhance them to better
the catheter. Similarly, if C1 is entered, the corresponding image
delineate the source or X-ray marker positions, the tar-
C2 on film 2 can be found. With this method, corresponding
get volume, and surrounding organs. They are distin-
image points can be found without the use of an X-ray marker in
guished by their position along the caudal-cranial axis
the catheter.
along the CT table top. The coordinates of an image of
a source or X-ray marker can be obtained with a point-
ing device such as a mouse. Reconstruction of the
case of implants with many catheters. In a lateral radi- localization is straightforward; the x-coordinate and
ograph only a cloud of X-ray markers is visible, but not y-coordinate are obtained directly from the mouse
the braided metal cables. In such an implant, continuous coordinates and the 2-coordinate is given by the table
radio-opaque wires should be used instead of the X-ray position of the slice.
markers.
As stated earlier, the isocentric reconstruction method
connects corresponding catheter describing points
5*4.4 Reconstruction accuracy
between the two X-ray images with parallel lines. The
localization of a catheter in space from its two images on
ACCURACY OF THE DIFFERENT RECONSTRUCTION
the isocentric film is reconstructed as follows. First, the
METHODS
two X-ray images of the catheter are described with
catheter image points. If on both X-ray images the The most accurate reconstructed catheter or source
catheter tip is clearly visible, the line connecting these coordinates are obtained when the central axes of the
tips is taken as the horizontal base line. This corrects for two projecting beams are perpendicular to each other.
any patient movement between the taking of the two This is achieved by the orthogonal reconstruction
exposures. Otherwise, the line connecting the images of method or by the variable angle method when the gantry
the isocenter is taken as the horizontal base line. angles differ by 90 (or 270). The accuracy remains high
With appropriate software, any set of variable angle if the angle between the two beams lies in the interval
radiographs taken with the same focus isocenter distance (60-120). A reconstruction set-up which uses an angle
can be converted to a computer-generated isocentric outside that interval, thus smaller than 60 or between
'radiograph' (Figure 5.7). Then each point with which a 120 and 180, becomes sensitive to patient shifts
catheter image is described can be connected by the between the taking of the radiographs and to digitizing
planning software to its corresponding point on the errors. The stereo-shift reconstruction method is
other image by a line parallel to the one connecting extremely sensitive to digitizing errors, due to the small
the images of the catheter tip. angle between the two projecting beams, up to 10, and
This conversion of the variable angle reconstruction should be used with great care [17]. The reconstruction
to the isocentric one is not possible with the semi- accuracy depends also on the use of X-ray markers.
56 Computers in brachytherapy dosimetry

Figure 5.7 Variable angle


reconstruction using isocentric
pseudo-film. The intersections
of the rays to the catheter
image points with a
computer-generated isocentric
plane are determined.
Corresponding images on the
pseudo-film are all connected
by parallel lines. This method
is suitable for reconstruction
of implants with flexible
catheters using a therapy
simulator. If the patient shifts
between the taking of the
radiographs, lines between
corresponding images are
parallel to the line connecting
the images of the catheter tip.

RECONSTRUCTION USING a OR MRI SLICES moved a certain distance between the taking of the two
radiographs, the resulting error in localization of the
The main factor determining the accuracy of the recon-
catheter describing point is only half that distance.
structed localization is the slice spacing, the distance
between consecutive slices. A typical value of 4 mm
RECONSTRUCTION USING CATHETER IMAGE
results in an accuracy of 2 mm in that direction. The
TRACKING
choice of the material for the catheters and the X-ray
markers is also essential because dense high Z material The accuracy of image tracking reconstruction depends
will introduce artifacts in the scan. strongly on any movement of the patient between the
taking of the two films. Because the projections of the tip
of a catheter on both radiographs are usually visible, the
RECONSTRUCTION USING CATHETER DESCRIBING
shift of this catheter due to a patient shift between the
POINTS
taking of the two radiograph images can be determined.
The localization in space of a catheter describing point One of the images can then be adjusted by the planning
from its two X-ray images is defined by constructing the system such that the rays from the X-ray foci to these
two rays projecting the catheter describing point to its first image describing points intersect. However, a rota-
X-ray images. These two rays will not intersect because tion of the patient cannot be taken into account and will
there will always be some movement of the patient result in an error in the reconstructed localization of the
between the taking of the two radiographs. The recon- source or wire. With catheter image tracking, the error in
structed localization of the catheter describing point is catheter localization due to a given patient movement is
taken halfway on the line connecting the two rays along about twice the error obtained with catheter describing
their shortest distance (Figure 5.8). Thus, if the patient points.
Optimization techniques in stepping source brachytherapy 57

rithms with varying user-defined constraints may all


deliver different dose distributions. Therefore, clinical
experience will always be needed to judge the mathemat-
ically optimized dose distribution for actual patient
treatment. Based on that judgement, changes may be
made in the optimization constraints, resulting in a new
optimized dose distribution, before the final dose distri-
bution will be accepted for clinical use.

5.5.1 Distance and volume implants

In mathematical optimization, two types of implants are


distinguished: distance implants and volume implants.
In a distance implant, dose points are placed at a given
distance around the catheters. The mathematical opti-
mization aims at determining the dwell positions and
Figure 5.8 Correction for patient shift between thetakingof relative dwell times such that the prescription isodose
radiographs 7 and 2. To find the localization of an X-ray marker, surface passes through these dose points [ 16,20,21]. This
the shortest distance between the rays to the corresponding is called 'optimization on distance.' Examples of distance
images of this marker is determined. The reconstructed implants are single catheters, double catheters, and
localization of this marker is placed midway on the line along single-plane implants. If digital imaging with transverse
this shortest distance. slices is used, these so-called dose points can be placed
equidistantly on the target contours in the displayed
cross-sections of the patient. With reconstruction by
radiographic films, dose points can be placed only rela-
5*5 OPTIMIZATION TECHNIQUES IN tive to the catheters.
STEPPING SOURCE BRACHYTHERAPY A volume implant contains one or more planes of
catheters. Series of dose points are placed inside the tar-
Once the catheters are placed in the patient, stepping get volume midway between the catheters and through-
source brachytherapy offers two degrees of freedom: the out the implant. In a volume implant, the relative dwell
dwell position and the dwell time. Usually, the dwell times are optimized to the same dose in these dose
positions are placed in the sections of the catheters that points. This is called 'optimization on volume' [16,21].
are inside the target volume. Then optimization of the The prescription dose is defined as a given percentage of
dose distribution is performed by manipulation of the the mean dose in these dose points, with the prescription
dwell times either by the user or by dedicated software. isodose surface encompassing the target volume as
Most optimization procedures do not determine the closely as possible. However, the above definition of opti-
absolute dwell times for each dwell position. Instead, mization of volume is a gross simplification. The place-
they result in a set of relative values for the dwell times in ment of dose points midway between the catheters alone
the range 0.0-1.0 with a corresponding set of relative is not sufficient for optimization (Figure 5.9).
dose values in the dose points. Another module of the In cases in which dose point placement is complicated
treatment planning program calculates the absolute due to irregularities in the distances between implanted
dwell times for the stated mean dose in these dose points. catheters, the dwell positions themselves can act as dose
There are several factors which influence a mathemat- points for optimization. This technique is called 'geo-
ically optimized dose distribution. For example, due to metric optimization' and can be performed either on
the radial nature of radiation from a point source, it is distance or on volume [16,23].
not possible to obtain along the axis of a catheter a pre-
scription isodose curve in the shape of a box. Also, if the
5.5.2 Rules of optimization
placement rules for the catheters of a given target vol-
ume are not adhered to, it is difficult, if not impossible,
Once a stepping source implant is optimized, it can be
to obtain a good dose distribution. Or, if an implant is
evaluated by the following rules.
not covering the target volume geometrically, manual
changing of relative dwell times may be required to cover Rule 1. The optimized isodose distribution should
the target volume with the prescription isodose surface. match the requirements specified by the physician. In
Thus, a mathematically optimized dose distribution does the case of a distance implant, the prescription isodose
not always represent the best possible one in and around surface should pass as closely as possible through each
an implant. Finally, different types of optimization algo- of the defined dose points. For a volume implant, the
58 Computers in brachytherapy dosimetry

Figure 5.9 Distance


optimization of a volume
implant. A two-plane implant
with five parallel catheters is
optimized to the same dose in
rows of dose points, placed
midway between the catheters. A
perfect fit is obtained by only
activating the central catheter. If
the sum of the squares of the
dwell times is minimized, the
central catheter is switched off.
Dwell positions 1-13 in each
catheter; step length 0.5 cm;
reference air kerma rate 4.0682
cGy h-1 m2, i.e., 10 Ci iridium-192.
: Active source dwell position;
O: Inactive source dwell
position; : Dose points, midway
between catheters along 6 cm
active length.

dose in the volumes midway between the catheters 5.53 Optimization of distance implants by
should be as homogeneous as possible throughout the least square minimization
implant.
Rule 2. The shape of the isodose surface close to the The aim in optimization of a distance implant is to have
applicator or catheters should be smooth and resemble the prescription isodose surface pass at a given distance
as closely as possible the shape of the isodose surfaces at from the dwell positions along the catheter(s). To
distances further from the catheter. accomplish this, dose points are placed at this distance
Rule 3. Active dwell positions should not extend from the implant, relative to the successive dwell posi-
outside the target volume. tions.
Rule 4. Optimization algorithms should be fast To obtain the best combination of dwell positions and
enough to keep the time between the application and relative dwell times, a mathematical object function
treatment to a minimum. must be minimized. This consists of the difference
The first rule of optimization addresses the optimiza- between the actual dose calculated at each dose point
tion goals of a distance and a volume implant. The sec- and the ideal dose requested. Usually, this optimization
ond rule aims at the minimization of hot or cold spots in problem is addressed by least squares minimization. In
the implant, especially close to the active dwell positions. that case, if there are N dose points, each receiving a dose
The third rule requires the active dwell positions to contribution from M sources (active dwell positions),
remain within the target volume, because extending then the following least squares function is to be mini-
beyond this boundary would increase dose to healthy tis- mized [16,21]:
sue. To satisfy this rule, the most distal dwell positions
must be increasingly weighted to account for the lack of
contributions of dose from adjacent dwell positions. The where N is the number of dose points, Dpi is the pre-
fourth rule minimizes the hardship to the patient by scribed dose to point i, and Dci is the calculated dose to
keeping the time that the catheters or applicators remain point i. (See the equations representing the prescribed
in the patient to a minimum. doses, Dpi, in Figure 5.10.)
Optimization techniques in stepping source brachytherapy 59

Figure 5.10 Optimization on distance


of the dwell times in a straight catheter
to prescribed doses in dose points along
the catheter. Dpi=prescribed dose in
dose point i; Dcj = calculated dose in
dose point i; Au = dose in point if mm
dwell position] for tt = 1, see equation
5.10. The Chi-square function x2 is
minimized by setting the derivatives
8%V8f,for each dose point i to 0 and
solving the resulting set of equations.

The dose Dci to a dose point i from each source j is cal- suppressing wildly varying values. The method of singu-
culated by using equation 5.3 for a point source: lar value decomposition (SVD) contains this additional
criterion [24]. The SVD method minimizes the least
square differences between prescribed and calculated
dose in the dose points. If there are fewer dose points
where than relative dwell times (i.e., fewer equations than vari-
ables), SVD also minimizes the sum of the squares of the
Sj is the source strength of source j: Sj = (Sk A)j
relative dwell times in order to arrive at a unique solu-
tj is the time that source j stays at distance ri,j
tion.
C( r i,qi,j) combines the radial dose function and the
anisotropy function:
DWELL TIME GRADIENT

When a set of equations linear in tj is solved, negative rel-


Ai,j is the dose contribution in point i from dwell ative dwell times may result. For example, in Figure
position j for tj = 1. 5.11 (a), an endobronchial application is simulated by a
single catheter with 25 dwell positions. It is optimized
In the case of a stepping source implant, the source
using 25 corresponding dose points at a lateral distance
strength Sj for all j sources is the same. Thus, the only
of 1 cm from each dwell position. The solution which
variable that can be altered to minimize equation 5.9 is
gives exactly the prescribed dose to the dose points
the dwell time tj at each dwell position j.
results in large positive and negative values for the rela-
x2 can be minimized by setting its derivative to each tj
tive dwell times in adjacent dwell positions. This is unac-
toO:
ceptable because large fluctuations will cause hot and
cold spots (a violation of the second rule of optimiza-
tion) and negative relative dwell times are a physical
impossibility. An unacceptable solution to this problem
In this way, M equations are obtained which are linear
is to set all negative relative dwell times to zero. In doing
in their M unknown tjs. There are a number of mathe-
so, the calculated dose in the dose points changes con-
matical procedures available to solve these equations.
siderably, which will offset the requirement of an equal
This results in a set of values for the tp. A problem arises
dose to each dose point.
when there are fewer dose points than dwell positions.
A solution to prevent these negative and strongly fluc-
Then, the set of equations is underdetermined and many
tuating relative dwell times was developed by Van der
mathematical solutions exist. To arrive at a unique solu-
Laarse et al. [16,19-21]. By gradually suppressing large
tion, an additional criterion must be supplied.
fluctuations of dwell times in adjacent dwell positions,
Intuitively, a suitable criterion would be to minimize the
the negative relative dwell times must eventually all
sum of the squares of the relative dwell times, thus become positive, because in the limit situation where all
dwell times are equal, they are positive (Figure 5.1 Ib). To
60 Computers in brachytherapy dosimetry

dwell time gradient restriction is applied to equation 5.9


as follows:

where w is the weighting factor for the dwell time gradi-


ent restriction. This expression remains linear in tj so x2
can be minimized as given by equation 5.11.
By increasing the weighting factor, w, the dwell time
gradient in adjacent dwell positions is reduced. This, in
turn, reduces the likelihood and magnitude of negative
relative dwell times (Figure 5.lib). The minimum value
for the weighting factor is the one that makes all values
of the relative dwell times positive or zero. As previously
stated, the concept of the dwell time gradient is based on
the second rule of optimization, which requires that the
isodose surfaces remain as close in shape as possible as
they get closer to the catheters. Thus, by requiring a
smooth transition of relative dwell times along the
catheters, smooth isodose surfaces will be obtained with
a minimum of hot and cold spots close to the catheters.

POLYNOMIAL OPTIMIZATION
Optimization of a distance implant by setting the deriv-
atives of x2 to each tj to 0 results in M equations with M
unknown tp. Thus, in an M x M coefficient matrix, with
M being the number of active dwell positions, large
implants may exceed the available memory of the plan-
ning computer. For example, an implant with 500 active
dwell positions requires the planning computer to solve
500 equations with 500 unknown tjs. Also, the computa-
tion times may become unacceptably long.
The dwell time gradient also offers a solution to this
problem. Because the differences between successive rel-
ative dwell times are smoothed, the relative dwell times
in a given catheter can be approximated by a continuous
function t(x) with x the distance to the catheter tip [16].
Figure 5.11 The influence of the dwell time gradient restriction
Thus, the relative dwell time at dwell position j with a
on the dwell times of a straight catheter implant optimized on
distance xj from the tip, is given by tj = t(xj). For t(x), a set
distance. By restricting the difference between the dwell times of
of polynomial functions, Pm(x), to the order m can be
adjacent dwell positions, an optimized solution with positive or
taken, similar to describing a continuous curve by a
zero dwell times is obtained, (a) Optimized relative dwell times
Fourier series expansion to a given order. Thus:
where there is no dwell time gradient restriction (DTGR) imposed
on dwell times of adjacent dwell positions. The maximum
difference of successive dwell times is nearly 2, the limit value.
(b) Optimized relative dwell times with a small DTGR of 0.01.
where m is the index, indicating the order of the polyno-
The maximum difference of successive dwell times is reduced to
mial Pm(x), am is the mth parameter, Pm(x) is the polyno-
1.2. (c) Optimized relative dwell times with a DTGR of 0.18. The
mial of order m, and p is the number of parameters
maximum difference of successive dwell times is 0.4. All dwell
required for an adequate approximation of tj by t(xj at all
times are positive or zero, so this represents the best possible fit
dwell positions x}. By inserting equation 5.13 into equa-
of an isodose line through the dose points.
tion 5.12, x2 is now expressed as a function of the p para-
meters am instead of the M relative dwell times tj.
Minimizing of x2 is again obtained by setting the deriva-
implement this limitation of the variance of relative tives dx2 da m to 0. This leads to a p x p coefficient matrix
dwell times between adjacent dwell positions, the so- instead of the M x M one when the derivatives of x2 to tj
called dwell time gradient restriction was developed. The are taken.
Optimization techniques in stepping source brachytherapy 61

mized to the shortest overall time possible, with positive


or zero dwell times and with the doses in the dose points
at least equal to the prescription dose [26].
A disadvantage of this technique is that the dose dis-
tribution is solely defined by these dose points, with no
regard to the dose distribution close to the catheters.
This may conflict with rule 2 of optimization, which
states that isodose surfaces near the catheters should be
smooth and resemble as closely as possible the shape of
the isodose surface through the dose points. Thus,
implants optimized by equation 5.14 often show the
occurrence of hot and cold spots at distances close to the
Figure 5.12 Relative dwell times as in Figure 5.Tib, with just catheters. Of course, this is not a problem when opti-
sufficient dwell time gradient restriction but now parameterized mizing a vaginal cylinder application, where the dose
in terms of distance along the catheter. t(x) is approximated by inhomogeneities are within the plastic of the applicator.
polynomials P(x) to the degree m with m<M. However, for an endobronchial implant, these volumes
with high and low doses are within the target volume.
Note. The concept of minimum dose points on circles
Take as an example a catheter with 33 active dwell
with a given radius around the dwell positions can also
positions (Figure 5.12). The value of p will be much
be applied using least squares optimization. First, evenly
smaller than 25 because, due to the dwell time gradient,
spaced dose points are constructed on the circle around
the dwell times are interrelated. A suitable value of p is
each dwell position, perpendicular to the catheter. The
given by p = 2 m - 1. Thus, the set of 25 tjs can be
radius of the circle is the distance to the prescribed dose.
described by nine parameters, am. This reduces the mem-
Then, all relative dwell times of the active dwell positions
ory requirements by a factor of 8, from 25 x 25 to 9 x 9.
are set to unity and the doses in these dose points are cal-
culated. Finally, for each circle around an active dwell
5.5.4 Optimization of distance implants by position, the point with the minimum dose is found and
linear programming stored. These points with minimum dose will always lie
in the area of lowest dose, even after optimization. They
Linear programming, as applied to stepping source define the surface of the treatment volume. The points
brachytherapy, solves the problem of minimizing a func- with minimum dose are now taken as dose points for
tion linear in the dwell times, subject to a finite number the polynomial optimization technique, previously
of constraints. These constraints are again linear in the described. This technique has the advantage of minimiz-
dwell times. The problem is formulated mathematically ing the effort of placing the dose points, like in the linear
as follows [25]: programming approach, but overcomes the problem of
irregular isodose surfaces close to the catheter by apply-
ing the dwell time gradient restriction.

5.5.5 Optimization of distance implants by


simulated annealing

Another optimization technique suitable for brachyther-


In the case of a distance implant, one can construct
apy treatment planning is simulated annealing. This
circles with a given radius around each dwell position
technique solves the optimization problem in a stochas-
which are perpendicular to the catheter. The radius of
tical way, using a directed random search for the dwell
the circles is the distance to the prescribed dose. Dose
times to seek the lowest value for an object function such
points are placed on the circles at equal angle intervals,
as defined in equation 5.14 [27]. Simulated annealing
e.g., every 15. The calculated dose, Dci, in each dose
proceeds iteratively as follows:
point i is required to be at least equal to the stated pre-
scription dose Drep thus Dci > Dref. Using equation 5.10, 1. An initial solution (set of dwell times and/or source
positions) is chosen and evaluated using the
this translates in equation 5.14 to ay= C(r i,j qi,j) objective function.
2. A new solution is constructed from the current one
and b = Dref, again M being the number of dwell positions
by varying the dwell times in a random direction
and N the number of dose points. If as object function
M
and by an amount which is initially large but
is minimized, taking cj = 1, the treatment is opti- decreases sufficiently slowly so that a global
minimum can be found. If the new solution is
62 Computers in brachytherapy dosimetry

better, it replaces the current one. If it is worse, it is of volume implants additional constraints are required.
accepted with a probability that depends on the These are provided by applying polynomial optimiza-
difference from the current one and on the size of tion with constraints obtained by geometric optimiza-
the change in dwell times. tion.
3. The process iterates with the amount of change in
dwell times being reduced sufficiently slowly such
GEOMETRIC OPTIMIZATION ON AMERICAN
that the system can search out the region in solution
VOLUME IMPLANTS
space containing the global optimum and converge
to it. Geometric optimization is an alternative approach to
optimization on dose points. It is based solely on the
This method has been applied by Sloboda [28,29] for
dwell positions on the assumption that they represent
planning low dose-rate treatments with trains of active
the target volume. Originally, it was applied only to those
and non-active pellets in the catheters. In this case, a step
stepping source implants for which the spacing between
is performed by switching an active position to an inac-
the dwell positions (the intracatheter spacing) is about
tive one, or the reverse. An evaluation of different imple-
equal to the spacing between the catheters (the inter-
mentations of simulated annealing in brachytherapy is
catheter spacing), typically 1-1.5 cm [16,23]. This type
given by Wehrmann et al. [30].
of implant is performed mainly in the USA. It results in
an equidistant, three-dimensional grid of dwell positions
5.5.6 Optimization of volume implants in the target volume (Figure 5.13).
The basic assumption underlying geometric opti-
A volume implant is any implant with two or more mization is that the dwell time in a dwell position is
planes. Polynomial optimization of a volume implant inversely related to the dose given in that position by the
aims to make the dose in the volumes midway between other dwell positions [23]. Take, for example, a dwell
the catheters as homogeneous as possible. This opti- position at the border of the target volume. It requires a
mization cannot be based on dose points alone. If dose larger dwell time than a dwell position in the center,
points are placed only outside a volume implant, the because it is further away from the other dwell positions
inner part of the target volume will be underdosed which all contribute according to the inverse square of
because the outer dwell positions will be used mainly to their distance (Figure 5.13).
deliver the required dose to these dose points. This is due Geometric optimization in treatment planning soft-
to the inverse square dependency of the dose on the dis- ware is based on the following two suppositions: (1) the
tance and to the minimization of the overall time by the dwell time at a dwell position is inversely proportional
optimization procedure. It is explained in a similar way: to the dose delivered by the other dwell positions; and
that the periphery will be underdosed if points were (2) the dose given by another dwell position is inversely
placed midway between the catheters. Of course, it is proportional to the square of its distance. So the influ-
possible to place dose points inside the implant and ence of source geometry and tissue scatter is disre-
around it at a given distance. However, except for very garded, i.e., the factor C(ri,j, qi,j) in equation 5.10 is
regular implants, it is not possible to determine the rela- assumed to be constant. Thus, the dose in a given dwell
tion between the doses in the inner points and in the position i is inversely proportional to the sum of the
outer ones. It is obvious, therefore, that in optimization inverse square of the distances from that point to all

Figure 5.13 Geometric optimization (GO) of a two-plane American-type implant with six catheters. Separation between the sources in
the catheters is about equal to the distance between the catheters. Calculation is midway between the planes, (a) No optimization.
Note the hot spot where the catheters converge, (b) Geometric optimization.
Optimization techniques in stepping source brachytherapy 63

other dwell positions j. So the relative dwell time tt at (I)


position i becomes

with ri,j the distance between dwell positions i and j, and


M the number of dwell positions.
Note the following:
Figure 5.14 Geometric optimization on distance. The relative
1. Using the inverse square of distances as doses in dwell time = 1/dosefrom all other dwell positions. (1) High dose
equation 5.15 is a simplification, but acceptable for contribution from both catheters. (2) High dose contribution,
iridium-192 or cobalt-60 sources. Of course, the sum mainly from both neighboring dwell positions. (3) Low dose
of the actual dose contributions from the other contribution, mainly from left neighbors. Thus, t1= t2 < t3.
dwell positions can also be used. Geometric optimization on volume. The relative dwell time =
2. The optimized dwell time in a given dwell position is 1/dosefrom dwell positions in other catheters. Dose
mainly determined by the dose contribution from its contributions by other catheter (1) - high, (2) = medium, (3) -
nearest neighbors. low. Thus, t1< t2 < t3.
3. Only relative dwell times are determined and one or
more dose points are still required to define the
prescription dose.
GEOMETRIC OPTIMIZATION ON EUROPEAN
An obvious advantage of this technique is its simplic-
VOLUME IMPLANTS
ity. However, this algorithm relies on good geometry of
the implant itself and on the intracatheter spacing being To optimize a European-type volume implant, a varia-
about equal to the intercatheter spacing. When catheters tion called geometric optimization on volume was devel-
converge, the algorithm tends to overcompensate by oped [21]. This variation uses in equation 5.15 only the
reducing the dwell times too much. Therefore, the con- distances between the dwell position i in the current
tribution from any dwell position at a distance less than catheter k and all dwell positions j in the other catheters.
a given threshold distance is ignored. On the other hand, If a given dwell position in a catheter is at a large distance
when the intercatheter distance is larger than the intra- from the ones in the other catheters, the dose contribu-
catheter one, the intracatheter distances dominate the tion will be small, resulting in a large dwell time. This
dwell time calculation and the separation between the will substantially increase the dose in the volume
catheters is insufficiently taken into account. between the dwell position and the other catheters
(Figure 5.14). The consequences of geometrical opti-
mization in pulsed dose-rate brachytherapy on
GEOMETRIC OPTIMIZATION ON EUROPEAN
European volume and distance implants are discussed in
DISTANCE IMPLANTS
detail by Berns et al. [22]
Interstitial brachytherapy in Europe is based on continu- Although geometric optimization on volume does not
ous wires of iridium-192, usually with interwire spacing require dose points, they are still required for the defini-
of 1.5-2 cm [3,4]. In stepping source dosimetry, these tion of the prescription dose. For a regular volume
continuous wires are replaced by a source stepping in the implant, the best position for the dose points is in the
catheters with a step length of 2.5 mm or 5 mm. Thus, in central transversal plane midway between the catheters.
a European-type implant with intracatheter spacing of 5 The prescription dose is then based on a given percent-
mm, the intercatheter spacing is two to four times larger. age of the mean dose in these dose points. A percentage
If geometric optimization is used as described above, of 90 is required for a distance of about 3 mm between
then the nearest dwell positions are always located in the the outer catheters and the prescription isodose line in
same catheter unless another catheter approaches within the central transversal plane. A more detailed discussion
the step length. Because the optimized dwell time in a about the prescription dose of an optimized implant is
given dwell position is mainly determined by the dose given in section 5.7.6.
contributions from its nearest neighbors, this results in a Geometric optimization alone of a European volume
cylindrical dose distribution around each catheter, simi- implant does not always suffice (Figure 5.15). It is not
lar to the ones obtained with polynomial optimization strong enough to keep all dwell positions inside the tar-
on distance with dose points placed laterally at 1 cm. So get volume. At the outer ends of the catheters, active
the geometric optimization procedure as performed on a dwell positions are needed on or even outside the target
USA volume implant results in optimizing on distance surface. In the next section, a combination of geometric
on a European implant. When applied on European-type and polynomial optimization is presented where all
implants, this technique is called geometric optimization active dwell positions are located inside the target
on distance (Figure 5.14). volume.
64 Computers in brachytherapy dosimetry

Figure 5.15 Intraluminal implant, optimized on distance, (a) Polynomial distance optimization on dose points placed at 1 cm
distance in region of minimum dose, away from the other catheter. Note that the WOO cGy prescription isodose runs through all dose
points, (b) Geometric optimization on distance of a European-type implant. The 1000 cGy prescription isodose is taken as the mean of
the dose values in the dose points. Note that the geometric optimization undercorrects when catheters coincide.

POLYNOMIAL OPTIMIZATION ON VOLUME target volume V = L x W x T a s a function of L, W, and


T, with L the length, Wthe width, and T the thickness of
As previously stated, European volume implants cannot
the target volume. The active lengths extend outside the
successfully be optimized based on dose points midway
target to correct for the bending of the prescription iso-
between the catheters alone. However, if an additional
dose surface in between the catheter ends. This is
constraint, supplied by geometric optimization on
because the Paris System applies wires of constant linear
European volume implants, is added to the least squares
activity and does not place a crossing catheter at the end
function x2 in equation 5.12, optimization on volume is
of the implant, as is done, for instance, in the Manchester
achieved [21]. This two-step process is called polynomial
System with a needle implant.
optimization on volume. In the first step, the geometric
As already described, the high dose-rate treatment of
optimization on volume is used to obtain the total rela-
volume implants is performed with a source stepping
tive dwell time for each catheter. The additional con-
through a set of catheters or needles. Thus, the Paris
straint now requires that the total relative dwell time for
Dosimetry System can easily be adapted to high dose rate
each catheter remains equal to the one obtained by geo-
by applying equidistant dwell positions with equal dwell
metric optimization. Thus, the total dwell time in each
times. If, however, the dwell times at the longitudinal
catheter, determined by geometric optimization, is redis-
ends of the catheters are increased by polynomial opti-
tributed by polynomial optimization in such a way that
mization on volume, the active dwell positions, even at
the dose points midway between the catheters all receive
the longitudinal ends, are kept inside the target volume.
the same dose.
This adaptation of the Paris System is called the Stepping
Polynomial optimization on volume is an essential
Source Dosimetry System (SSDS) [16,31].
part of the Stepping Source Dosimetry System, which is
The SSDS uses the same rules for implantation as the
presented in the next section.
Paris Dosimetry System, except that the active lengths in
the catheters remain within the target surface, even at the
longitudinal ends. Dose points are placed midway
5.6 THE STEPPING SOURCE DOSIMETRY
between the catheters over the whole length of the
SYSTEM
implant. When an implant is very regular, for example
when templates are used to maintain the prescribed dis-
Before the use of computers in brachytherapy, the Paris tances between the catheters, the first and the last dose
Dosimetry System was developed as a low dose-rate point of each row midway between the catheters should
dosimetry system using afterloading of iridium-192 be discarded. The SSDS applies polynomial optimization
wires with equal linear activity into thin flexible on volume to obtain the same dose in these dose points.
catheters or rigid needles [3,4]. For a given target vol- Originally, the SSDS defined the prescription dose as
ume, the Paris System gives rules on how to implant a 85% of the mean dose in these dose points [16,31]. As
Dose-volume histograms 65

discussed in section 5.7.6, where non-optimized and A comparison of an isodose distribution for a breast
optimized implants are compared, the prescription dose implant using the Paris System and the SSDS is shown in
is best defined as 90% of the mean dose in the dose Figure 5.16. The optimized dose distribution shows a
points. more homogeneous dose distribution inside the target
volume and an appreciable dose reduction outside it. A
more graphical and quantitative approach for the evalu-
5.6.1 Summary of the Stepping Source ation of a dose distribution is given by its differential or
Dosimetry System natural volume dose histogram, presented next.

The following parameters are used in the SSDS:


L =
length of the target volume 5.7 DOSE-VOLUME HISTOGRAMS
T =
thickness of the target volume
S =
spacing between the catheters
Dose-volume histograms (DVHs) play an important
M =
the safety margin around an implant: it is the
role in evaluating the dose distribution in and around an
distance between the prescription isodose and
implant [32,35,36]. A DVH of a dose distribution is rep-
the active lengths in the outer catheters in the
resented as a graph with a series of dose intervals on its
central transversal plane
horizontal axis, and, on the vertical axis, for each dose
AL = active length in a catheter: it is the distance
interval, a volume related to that dose interval. Such a
between the first and the last active dwell
dose interval in a histogram is called a bin. For example,
position inside the target volume.
if 1000 bins are taken for a dose range of 500-2500 cGy,
The SSDS implantation rules are as follows. the first bin, DD1 will be 499-501 cGy, the second bin,
DD2, will be 501-503 cGy, etc., with the bin width AD
For a short target volume, L < 5 cm, the catheter
being 2 cGy.
spacing S varies between 8 mm and 15 mm; for a long
A differential DVH is a graph with dose intervals ADj
volume, L > 5 cm, S varies between 15 cm and 22 cm.
on the horizontal axis and on the vertical axis, for each
For a target thickness T < 12 mm, single-plane
dose interval DDi the ratio AV/AD with DVi the volume
implants are applied, with the catheter spacing
receiving a dose between Di - 0.5 AD and Di + 0.5 AD. In
S T/0.6, which gives M 0.35 S.
a clinically useful histogram, AD is much smaller than Di.
For a target thickness T > 12 mm, double-plane
Then the volume with a dose between Di and Dj is given
implants are used. A double-plane implant with a
by the area under the histogram between Di and Dj If a
catheter pattern in triangles must conform to
volume implant is optimized to the same dose midway
S 271.3. The safety margin Mbecomes M 0.2 S.
between the catheters, all the volumes midway between
For a double-plane implant with a catheter pattern in
the catheters will obtain that dose and the differential
squares, S 271.6 and M 0.3 S.
DVH will show a sharp peak for that dose. Based on this
The active dwell positions at the longitudinal ends of
behavior, a differential DVH can be used to assess the
the catheters are placed inside the target volume using
homogeneity of the dose distribution of a volume
the safety margin as given above, AL = L 2M.
implant.
The dwell position spacing is 5 mm.
A cumulative DVH has the same horizontal axis of
The dwell times are obtained by polynomial
dose intervals Di;, with bin width AD, as the differential
optimization on volume, using dose points midway
DVH. On the vertical axis, however, is given the volume
between the catheters along their whole active
receiving at least the dose Di - 0.5 AD for each DDi. In a
lengths. The first and the last dose point of each row
clinically useful histogram with AD much smaller than
midway between the catheters are usually discarded.
Di, the histogram presents for each Di the volume
The prescription dose is defined as 90% of the mean
encompassed by the isodose surface(s) of that dose.
dose in these dose points. As they are all optimized to
Thus, the cumulative DVH of the target volume can be
the same value, this definition is equivalent to 90% of
used to determine those parts of the target volume that
the mean basal dose points in the central transversal
are either underdosed or overdosed.
plane.
In a clinical case, the dose distribution around an
The above rules are guidelines on how to implant a implant is so complex that a DVH can only be deter-
given target volume. The resulting dose distribution must mined numerically, thus a discretization of the three-
be evaluated by assessing the isodose lines in several trans- dimensional dose distribution in and around the
versal and longitudinal planes. In order for the prescrip- implant must take place. It is common practice to con-
tion isodose surface to encompass the target volume as struct a grid of equidistant dose points inside a rectan-
closely as possible, dwell positions may have to be acti- gular box, placed around the implant with a given
vated or deactivated and dose points to be added or margin. A sufficient number of grid points is placed
removed, both near the longitudinal ends of the catheters. inside the box and the dose in each one of them is
66 Computers in brachytherapy dosimetry

Figure 5.16 Two-plane breast implant with seven catheters. The length of the target volume is 8 cm. The active length, i.e., distance
between first and last dwell position, is 10cm for Paris System implant, and 7 cm for SSDS implant. Step size is 5 mm. The 500 cGy lines
are the prescription isodose lines determined according to the rules of the Paris System and the SSDS System, respectively, (a) Dose
distribution in the central transversal plane. The solid HneZ=0 indicates the central longitudinal plane, midway between the two
planes, (b) Dose distribution in the central longitudinal plane. The solid line indicates the central transversal plane, (c) Comparison of
the dose distributions in three longitudinal planes of the Paris-type and the SSDS implant. PlaneZ=0is the central longitudinal plane;
plane Z=-8 is the plane through needles 4, 5, 6, and 7; plane Z=+8 is the plane through needles 1,2, and 3. The upper part of each
dose distribution is given by the SSDS implant, the lower part by the Paris implant.
Dose-volume histograms 67

voxels ni with a dose value between Di 0.5 AD and Di +


0.5 AD, multiplied by the voxel volume v; thus DVi = n- v.
A cumulative DVH gives for a given dose interval (Di
0.5 AD, Di + 0.5 AD) the corresponding volume Vi,
defined as the sum over all voxels with a dose equal to or
exceeding Di - 0.5 AD, thus Vi =

When a three-dimensional equidistant grid of points


over the implant is used, a large number of grid points,
between 50 000 and 200000, is needed for an accurate
DVH. This is due to the application of an equidistant
grid over the regular geometry of the implanted
catheters, which leads to a large redundancy of grid
points. It can be proven statistically that a more efficient
grid over a set of regularly implanted catheters is a grid
where the x, y and z coordinates of each point are deter-
mined randomly [16,33]. The voxel size is then equal to
the volume of the rectangular box around the implant,
divided by the number of grid points inside the box. The
number of randomly placed grid points needed for an
accurate DVH lies between 10 000 and 50 000.
The target volume is defined by the tumor and the
margin around it. The minimum peripheral dose
(MPD), is defined as the dose of the isodose surface that
just encompasses the target volume, thus the highest
dose still encompasses the target volume. The treatment
volume is defined by the prescription isodose surface
which is selected by the radiation oncologist when view-
ing the dose distribution. The prescription dose (PD) is
the dose prescribed to the prescription isodose surface. If
CT or MRI images with the contours of the target vol-
ume are not available, the target volume is considered to
coincide with the treatment volume and the MPD is
taken to be equal to the PD.

5.7.1 Differential dose-volume histogram


of a single point source

Understanding of the properties of a DVH of a single


point source is essential for the evaluation of implants
with more sources. If a point source is ideal, i.e., tissue
scatter and absorption can be ignored, then D = S/r 2 ,
with D the dose at distance r from the source. The values
Figure 5.16 cont. of the differential DVH for an ideal point source can be
calculated directly [16], because the isodose surfaces are
spheres with the source as center, of which the volumes
calculated. Each grid point is the center of a cubical vol- are easily calculated by V= (4/3) p r3. For an ideal point
ume element, a voxel. The whole voxel is considered to source with D = S/r2, Vcan be written as a function of D:
receive the same dose as the grid point. When a three-
dimensional equidistant grid with spacing s is applied,
the voxels are cubes with edge s, which are centered The numerical and analytical value of (DV/DD) for D =
around the grid points. 1000 cGy will be calculated for an ideal point source with
More explicitly, a differential DVH gives, for a given S = 1000 cGy cm2. The numerical calculation requires the
dose interval (Di - 0.5DD,Di+ 0.5 DD), the correspond- distance r at which D = 1000 cGy: r = s/D = 1 cm. The
ing ratio DV/DD, with DVi the volume with a dose value value of (AWAD) for D = 1000 cGy is found by calculat-
in that interval. DVi is obtained from the number of ing D and V for r equal to 0.99 cm and 1.01 cm. For
68 Computers in brachytherapy dosimetry

r = 0.99 cm, D099 = 1000/0.992 = 1020 cGy and V099 = (4/3) very low doses from the sources, and essentially respond
n 0.993 = (4/3) p 0.997 cm3. For r = 1.01 cm, D101 = to all sources as a single source with strength N S.
1000/1.012 = 980 cGy and V,01 = (4/3) p 1.013 = (4/3) p Correspondingly, for these distant points the histogram is
1.03 cm3. Thus, DD = D1.01 - D099 = -40.0 cGy and DV = dWdD = -2 7p(NSY3/2 D 5/2 . For points of very high doses,
Voi -V0.99= 0.08 p cm3 This results in (DV/DD) = -0.002 thus very near to a source, only the dose contribution of
p = -0.0063 cm3 cGy-1 for D = 1000 cGy. that source will be seen, due to the inverse square depen-
Analytically, the differential DVH for an ideal point dence of the dose on distance. Now the histogram shows
source with D = S/r2 is given by, using equation 5.16: the behavior of N times that of a single source: dV/dD =
- 2 p N S3/2 D-5/2, which equals, of course, the DVH of a
single point source with strength N2/3 S. For a large
For S = 1000 cGy cm2 and D = 1000 cGy, dWdD = -2p number of sources, this strength is much smaller than
10003/2 1000'5/2 = -0.0063 cm3 cGy-1. See reference 16 for that at a large distance from the implant (Figure 5.18).
more details. Consequently, the influence on the dose distribution of
A differential DVH of an iridium-192 point source is the catheter placement and the dwell time optimization is
given in Figure 5.17. As in the above example, the dose at reflected most strongly in the middle section of the dif-
1 cm given by this source is 1000 cGy. At such a short dis- ferential DVH, which lies between about 75% and 200%
tance, the tissue scatter and absorption factor is near of the PD which encompasses the target volume. Visual
unity. From the dependence of dWdD on 1/D5/2, it is evaluation of this influence is difficult because of the
clear that, as the dose decreases, dV/dD increases more underlying inverse square law influence. In Figures 5.18
than quadratically. and 5.19, the differential DVH of a point source located
in the center of the implant is also given. The difference
between the point source curve and the implant curve
5.7.2 Differential dose-volume histogram indicates how much better the implant is compared with
of multiple point sources a single source. The strength of this point source is
defined such that the dose value of the spherical isodose
A differential DVH of a volume implant behaves as a sin- surface that just fits inside the rectangular grid box equals
gle point source for very low doses and for very high that of the similarly fitting isodose surface given by the
doses. This is illustrated in the case of an implant consist- implant. The margin of the grid box around the implant
ing of N identical point sources each with strength S is 1 cm. To determine the dose value of that spherical
(Figure 5.18). Points far away from the implant receive isodose surface, the maximum dose occurring on the

Figure 5.17 Differential dose-volume histogram of an iridium-192 point source which delivers WOO cGy at 7 cm in tissue. The
influence of tissue scattering and absorption is hardly visible, as is indicated by the histogram value for D = 300 cGy and the theoretical
value, using dV/dD = -2p S3/2 D- 5/2 for an ideal point source. A shaded area between two dose values represents the volume between the
corresponding three-dimensional isodose surfaces. For a discussion of the three shaded areas of equal size, representing three equal
volumes, see 'Natural dose-volume histogram,' p.69.
Dose-volume histograms 69

Figure 5.18 Differential dose-


volume histogram of the two-
plane breast implant of Figure
5.16, according to the Paris
Dosimetry System. The lower
peak is related to the volumes
between the outer catheters, the
higher peak to the volumes
between the inner catheters. The
underlying curve is the
histogram of the point source in
the center of the rectangular box
around the implant. The
strength of the point source is
such that the same maximum
dose on the grid surface is
obtained as given by the
implant. Note that the peak of
this histogram is not well defined
and the location of the 85% peak
dose value D85 is not at the base
of the peak.

rectangular box surface must be found. From that maxi- have been developed [39]. However, to evaluate an
mum dose value on the box surface, the source strength of implant implies evaluating the differences between the
the point source in the center of the box is calculated. This histogram of the implant and that of the corresponding
explains why both curves in Figures 5.18 and in 5.19 start point source in its center (see Figures 5.18 and 5.19). To
with the same dV/dD value for the minimum dose of 40.0 address this problem, Anderson [34] in 1986 developed
cGy. Figures 5.18 and 5.19 present various dose values the concept of the natural DVH and derived the
around the peak dose D100 to judge the implant. D100 is Uniformity Index (UI) as a figure of merit of the
defined as the largest difference between the dose his- implant. Based on the natural DVH, a new figure of
togram of the implant and that of the ideal point source. merit was defined, the Quality Index (QI) [22,35,36].
So D100 is the dose under the peak after correction for the
slope by the ideal point source. D85, D95, D105, and D115 are
dose values of 85%, 95%, 105%, and 115% of D100. Note 5*73 Natural dose-volume histogram
that D100 is located in the center of the implant and that
the dose range where the implant differs from the point Because the inverse square law has such a detrimental
source extends only about 15% from the peak dose D100. effect on interpretations of the differential DVH,
D85 is usually taken as the PD for an implant which is not Anderson [34] introduced a new dose unit, u, for the
optimized. Figure 5.19 indicates that, for an optimized horizontal axis: u(D) = D-3/2. Now, for an ideal point
implant, the implant histogram value for DS5 already source, using equation 5.17 and dV/dw = (dV/dD)/
approaches the point source histogram. As discussed in (dD/dw), it follows:
section 5.7.6, the PD for an optimized implant should be
taken as 90% of the peak dose D100.
It is possible to evaluate an implant by its differential which is independent of dose D, thus the natural his-
DVH. In addition, figures of merit based upon DVHs togram of a point source is a horizontal line (see Figure
70 Computers in brachytherapy dosimetry

Figure 5.19 Differential dose-


volume histogram of the two-
plane breast implant of Figure
5.16, optimized according to
SSDS. The single high peak is
caused by the optimization to
the same dose of all volumes
midway between the catheters.
The underlying curve is again
the histogram of the point
source in the center of the
rectangular box around the
implant (see Figure 5.18). Note
that the 85% peak dose value
D85 is not located at the base of
the peak and therefore is
unsuitable as prescription dose.

5.20). Note that the horizontal axis is linear in u, thus


linear in D-3/2. Also, that for increasing dose, u decreases.
Thus, when expressed in dose D, the low dose section of
this axis is expanded and the high dose section is com-
pressed. The area under the curve between Dl and D2 is
proportional to the volume between the Dl isodose sur-
face and the D2 isodose surface. Note the difference in
appearance of three equally sized volumes in the differ-
ential DVH of Figure 5.17 and the natural DVH of
Figure 5.20.
The natural DVHs of the unoptimized and optimized
two-plane breast implants discussed in section 5.6 are
given in Figures 5.21 and 5.22. The peak of the histogram
represents the volumes, midway between the catheters,
that receive an approximately uniform dose. The nar-
rower the peak, the more uniform the doses in the vol-
umes between the catheters. The narrowest peak is Figure 5.20 Natural dose-volume histogram of an iridium-192
obtained by an equidistant three-dimensional grid of source which delivers 1000 cGy at 1 cm in tissue. The - sign of
dwell positions over the target volume with the dwell dV/du is disregarded. indicates the actual histogram.
times optimized to the same dose in dose points between indicates the theoretical value of 132.5 using equation
the dwell positions. The broader the peak, the less desir- 5.19. The three equal volumes of Figure 5.17 now show up as
able the implant, until finally a horizontal line remains areas with equal base, indicating the compression of the dose axis
which represents a single point source in the center of for high dose values and the expansion for low dose values.
Dose-volume histograms 71

Figure 5.21 Natural dose-volume histogram of the two-plane breast implant of Figure 5.16, according to the Paris Dosimetry System.
(See legend of Figure 5.18 for explanation of the occurrence of two peaks.) Line (3) represents the theoretical limit, (4/3) p (nS)3/2 of
dV/du at a large distance from the implant, with n the number of dwell positions and S = D(r) r2 the source strength of the ideal point
source. Line (2) lies midway between lines (1) and (3) and defines the so-called 'low dose.' Line (5) represents the theoretical limit (4/3) p
p S3/2 of dV/du for very high dose values. Line (4) lies midway between line (1) and (5) and defines the so-called 'high dose.' The
prescription dose (PD) is defined as 85% of the mean dose in the basal dose points. See p. 72 for explanation of the Uniformity Index
and the Quality Index.

Figure 5.22 Natural dose-volume histogram of the two-plane breast implant of Figure 5.16, optimized according to the SSDS System.
The prescription dose (PD) is defined as 90% of the mean dose in the basal dose points, i.e., 90% of the peak dose value. Note the
relatively small change in the Uniformity Index compared to the unoptimized case (Paris System) in Figure 5.21 (2.26 versus 1.98). The
horizontal tails at the left side (very low dose values) and the right side (very high dose values) are explained on p. 71. The prescription
dose coincides with the natural prescription dose (NPD), which lies at the base of the peak at the LD side (see p. 74).

the target volume. It should be noted that only volume doses as if a single point source exists, and the natural
implants will show a peak in their natural histogram. DVH will thus display a horizontal line for these values.
As discussed in the section 'Differential DVHs of mul- Also, for very high doses, the histogram behaves as if a
tiple point sources', the histogram behaves for very low point source, although with much less strength, exists
72 Computers in brachytherapy dosimetry

(Figure 5.22). Because of the strong contraction of the QUALITY INDEX


w-axis for high doses, the horizontal line at the high dose
To compare different geometries of implantation and
end is sometimes hardly visible and appears as if it runs
different dwell time optimization schemes, another
straight down to this high dose limit value of dV/du
Figure of Merit is needed, which is independent of the
(Figure 5.21).
PD. For this purpose, the Quality Index is introduced
Anderson derived the Uniformity Index by taking the
[ 16,39]. In the Quality Index, LD is substituted for PD in
ratio of the volume under the peak, normalized to the
equation 5.20. Thus:
w-scale, and the volume encompassed by the isodose sur-
face of the target dose, again normalized to the w-scale. A
related Figure of Merit is the Quality Index, which is
independent of the target dose [22,35,36]. The quantities
A detailed study of the differences between UI and QI
PD, LD, and HD are used in these indices. PD refers to
in geometrically optimized breast implants is given in
the target dose prescribed by the radiation oncologist.
reference 22.
Usually, it belongs to the isodose surface which encom-
passes the target volume with a margin of about
3-5 mm. LD refers to the dose value at the half height of 5.7.4 Cumulative dose-volume histogram
the peak in the low dose region. This half height is mea-
sured from the limit value of the histogram for dose val- The cumulative dose-volume histogram (CDVH) pre-
ues approaching 0. HD refers to the dose value at the half sents for each dose value the volume encompassed by the
height of the peak in the high dose region. This half isodose surface(s) of that dose [51,52]. It is widely used
height is measured from the limit value of the his- to determine if a part of the target volume is underdosed
tograms for doses approaching infinity. or if an organ at risk is overdosed. The CDVH of the tar-
get volume shows a distinct behavior (Figure 5.23). For
dose values lower than the minimum peripheral dose,
UNIFORMITY INDEX
the complete target volume is covered and the CDVH
The Uniformity Index is a quantitative index to assess runs horizontal. When the dose value exceeds the mini-
how well the dose distribution covers the target volume. mum peripheral dose, part of the target volume is not
It is defined as the volume between the dose values of PD included by the isodose surface with that dose value, so
and HD, normalized to the w-interval between PD and the CDVH runs steeply downward with increasing dose.
HD, divided by the volume encompassed by PD, nor- For high dose values, only the small volumes directly
malized to the w-interval between PD and infinity dose. around the sources inside the target contribute and the
Thus, the Uniformity Index is: CDVH value decreases slowly.

5.7.5 Evaluation of dose distributions with


dose-volume histograms
with V(PD) the volume encompassed by the prescrip-
tion isodose surface, V(HD) the volume encompassed by
DVHs play an important role in evaluating the following
the high dose isodose surface, w(PD) the w-value corre-
aspects of dose distributions in brachytherapy [32].
sponding to the prescription dose, and w(HD) the
w-value corresponding to the HD value. How homogeneous is the dose distribution of a volume
By substituting u = D-3/2 and using u( ) = 0, we get implant? This can be assessed independently of the
actual PD, either by visual inspection or by the QI of
the natural DVH. Note that it is not possible to
evaluate the homogeneity of a distance implant,
The first term of the UI is the volume under the peak because of the steep gradients around the catheters.
extended to the target dose, divided by the width of the The differential and natural DVHs assess the
peak extended to the target dose. The narrower the peak, regularity of the catheters and the optimization of the
the larger the first term will be. The effect of the second dwell times, irrespective of the coverage of the target
term is the opposite. For a single point source, there is no volume by the implant.
peak and the UI = 1. How well is the dose distribution covering the target
As already mentioned, the UI is dependent upon the volume? This depends on the PD selected. It can be
PD chosen by the radiation oncologist. It is a measure of assessed again by visual inspection. It is obtained from
the quality of the dose distribution within the selected the CDVH of the target volume by looking at the
target dose. If a perfectly regular implant is not covering amount of the target volume which is underdosed by
the target volume completely and therefore a lower PD a dose less than the PD. The cumulative DVH is also
must be selected, this is reflected by a lower value of the used to determine the amount of volume being
UI. overdosed by, for example, a dose greater than 2 x PD.
Dose-volume histograms 73

Figure 5.23 Cumulative dose-volume histogram of the target volume of a non-optimized prostate implant. On the horizontal axis is
given the dose relative to the prescription dose (PD). On the vertical axis is given the encompassed volume for each dose value, relative
to the target volume V. The minimum peripheral dose (MPD) is the highest dose still encompassing the target volume. If the PD was
taken to be equal to the natural prescription dose (NPD), it is evident that the implant is not covering 10% of the target volume.
Additional dwell positions must be activated in the missed volume (see p. 74). The dose/non-uniformity ratio for a non-optimized
implant, defined as DNR(D) = V(1.5 D)N(D), will show a minimum for the PD in this histogram as the curve slope is the steepest in the
dose range PD-1.5 PD (see p. 74).

The UI of the natural DVH, which is based on the PD, implant. The 85% of the mean basal dose in the central
scores the combination of aspects (1) and (2) only if transversal plane coincides more or less with the mini-
the PD equals the minimum peripheral dose of the mum peripheral isodose, i.e., the isodose surface with
target. Thus, much more detailed information is the highest value, which still encompasses the complete
obtained when the dose homogeneity is evaluated implant. In the natural DVH of the unoptimized breast
with the QI of the natural DVH and the coverage of implant in Figure 5.21, the prescription dose PD lies
the target volume with the CDVH. about halfway on the left side of the peak.
How much volume outside the target volume receives a An SSDS implant shows a much more homogeneous
high dose? If CT or MRI images of an organ at risk are dose distribution inside the implant, which corresponds
available, the volume which receives a dose exceeding to the pronounced peak in the natural DVH of Figure
the maximum dose allowed in that organ can be 5.22, and a steep inverse-square-law dose gradient
determined. Then, a grid of dose points must be around it, which corresponds to the horizontal his-
placed over the organ at risk and the CDVH of that togram curves away from the peak (see, again, Figure
organ be determined. Similarly, the difference 5.22). The mean basal dose is practically equal to the
between the treatment volume and the target volume mean dose in all dose points midway between the
can be assessed by the CDVH of the treatment catheters, because these points are all optimized to
volume. the same value. Figure 5.24 shows that the isodose sur-
face with a dose value of 90% of the mean basal dose
The last two aspects are strongly related to the value of
coincides with the highest dose value still lying in the
the PD. In a volume implant with an optimized dose dis-
steep dose gradient area around the outer needles of an
tribution, dwell time has been moved from the center of
implant, and maintains a margin of a few millimeters
the implant to its periphery. This results in a steeper dose
around the implant. Therefore, the PD of an SSDS
gradient around an optimized implant, which influences
implant is taken as 90% of the mean basal dose. This PD
the definition of the PD and the treated margin around
isodose surface shows a smaller margin around the outer
the outer dwell positions.
dwell positions, due to the steeper dose gradient around
an optimized implant and the higher percentage of the
5.7.6 Definition of the prescription dose in basal dose (see Figure 5.24). This margin is about 3 mm,
non-optimized and optimized volume whereas the treated margin around a non-optimized
implants implant is about 5 mm. This definition defines a PD
which for an optimized implant lies at the base of the
A non-optimized Paris-type dose distribution displays a peak of the natural DVH, at the LD side.
low dose gradient which starts from the center of the To define the PD as the dose value at the base of the
74 Computers in brachytherapy dosimetry

In clinical practice, the PD is often taken as equal to


the MPD. If the target volume is suitably covered by the
implant, the NDR has a value nearly equal to one. If the
target volume is not suitably covered by the implant,
cold spots in the target volume will arise, around which
the MPD runs. Or, stated differently, the volume encom-
passed by the NPD covers the target volume only partly.
Thus, an ill-covered target volume prescribed to the
same MPD as a well-covered target volume will receive
an overall much higher dose. This translates into values
of NDR greater than one. NDR equal to 1.4 means that
the base of the peak of the natural DVH starts at 1.4 PD
and the whole target will receive a 40% higher dose than
when treated to the same PD but with an NDR equal to
Figu re 5.24 The definition of the prescription dose for an 1.0.
implant, according to the Stepping Source Dosimetry System. The use of NPD, MPD, and NDR is of utmost impor-
The 90% value of the mean basal dose (BD) in the central tance for implants of the prostate [61]. If the NDR is
transversal plane is the highest percentage still lying in the steep larger than 1 or, stated differently, if the required pre-
dose gradient area around the implant, thus just at the base of scription dose does not lie at the base of the peak of the
the peak in Figure 5.22. The treated margin around the outer natural DVH, a part of the target volume is not covered
sources is about 3 mm. Note that the 95% isodose line shows by dwell positions (or by seeds, in the case of permanent
deep bends between the catheter intersections. implants). All transverse slices should then be inspected
visually for target areas with a dose lower than the NPD,
and dwell positions in these areas should be activated (or
seeds be placed).

peak of the natural DVH is generally valid for all volume


implants. It is the value of the isodose surface inside
5.7.7 Other methods for evaluation of
which the optimized dose distribution lies and outside
dose distributions
which the inverse square law predominates. This defini-
tion of PD is called the natural prescription dose (NPD).
Another assessment of implant quality, utilizing only the
Note that this PD is defined on the dose distribution
CDVH, is given by the dose-non-uniformity ratio
only. The PD that covers the target volume is the mini-
(DNR) [53,54] for the homogeneity of the dose distrib-
mum peripheral dose (MPD). If the NPD is equal to the
ution and the coverage index (CI) for the target coverage
MPD, the implant is well placed over the target volume
[38]. The DNR ratio is a graph for each dose value of the
and the PD can be taken as equal to the MPD. The UI
ratio of the volume receiving a dose larger by a given
now correctly scores both aspects of the dose distribu-
fraction, say 50%, to the volume enclosed by that given
tion, the dose homogeneity and the target coverage.
dose value. Thus, for a given dose value, D:
If, in the natural DVH in Figure 5.22, the PD is taken
with a value lower than 90% of the mean basal dose, the
PD will shift more to the left on the horizontal tail for
The behavior of the DNR versus dose plot can be
low dose values. This implies that the PD is taken at a
correlated with implant quality in the target volume.
distance so far away from the implant that the inverse
For non-optimized implants, the fraction is usually
square law dominates. The UI will decrease correspond-
taken as 50%. In Figure 5.23, it is indicated that the
ingly.
minimum value for DNR(D) is defined by the 50%
Thus, according to the dose distribution, the PD
dose range where the volume curve has the steepest
should coincide with the NPD at the base of the peak in
slope and thus the difference between V(D) and V(1.5
the natural DVH (Figure 5.22). According to the target
D) is maximal. The steeper the CDVH curve between
volume, the PD should coincide with the MPD, the high-
D and 1.5 D, the better the dose distribution and the
est dose value still encompassing the target volume. If
smaller DNR(D) will be. However, the relation between
the PD does not match these two requirements, the dose
the minimum value of DNR and the MPD is defined
distribution does not cover the target volume adequately.
by the shape of the CDVH, and there is also no direct
This matching is evaluated by the natural dose ratio
relation with the NPD, as the latter is based on the
(NDR), which is defined as the ratio of the NPD and the
implant dose distribution and not on the target vol-
PD:
ume. DNR(PD) is also known as the Dose
Homogeneity Index (DHI) [37].
Three-dimensional imaging techniques 75

For optimized implants, it is better to take the fraction [40-3,51]. Unfortunately, compared to catheter and
as 25% [55]. This is explained as follows. The differential anatomical point reconstruction from two radiographs,
histogram in Figure 5.19 shows that the dose range the localization of catheters or individual source posi-
where the optimized implant differs from a single point tions using their intersections with CT slices is more
source in the center of the target is only 15% of the difficult.
peak dose. As discussed in section 5.7.6, the PD of an The entry of anatomical structures into the planning
optimized implant is 90% of the peak dose; thus, the system is achieved either by digitizing these structures
dose range PD-1.25 PD just covers the volume under the from a hard copy of the CT slices on a digitizer tablet or
peak. From this follows that the DNR value will be by delineating these structures by mouse on the com-
smaller for dose values other than 90% of the peak dose, puter display. Usually, only the target and critical struc-
and the plot of DNR(D) versus D will show a minimum tures are entered, because the other internal structures
at D equal to 90% of the peak dose. (For more details, see are of no clinical significance and are not taken into
reference 55.) When adapting the fraction to the amount account by the dose calculation routines in brachy-
of optimization performed, the minimum value of merapy.
DNR(D) will not distinguish for different types of Reconstruction of source locations from CT images
optimization. poses several problems, especially if the spacing
Depending on the regularity of the implant and the between the slices is large. When an X-ray ruler is used
type of optimization performed, the differential (and to reconstruct a catheter, markers may fall between the
natural) DVH will show different peak widths and, as a slices and a high resolution scout view is then required
result, different fractions are required in relation (22), to indicate which marker is visible in a given slice. For
ranging from 25% for a regular, fully optimized implant that reason, X-ray rulers are often used which consist
to 50% for a non-optimized implant. A detailed discus- only of a single radio-opaque wire. If the tip of such a
sion is given by Low and Williamson [55], in whose arti- marker wire falls between two slices, the intersections
cle different optimization schemes were applied to of the marker wire in the first two CT slices must be
different implant types but a fixed fraction of 25% was used to extrapolate the marker wire over the distance
taken. between the first slice and the tip of the marker wire.
The Coverage Index (CI) scores the coverage of the The reconstruction of a looping catheter requires the
target volume by the PD. It is defined as: differentiation in several slices between the images of
the two sections of the loop. In general, in order to get
the best reconstruction of a looping catheter, a small
interslice distance is required, resulting in the necessity
In the CVDH of the target volume, V(target) is equal to of handling a large number of CT slices. Dwell posi-
V(MPD). If PD is based on the minimum value of the tions in these needles are calculated by the planning
DNR(D) plot, then CI will be less than 1, about 0.9 for a system, using the distance of the first dwell position
non-optimized implant [55] (see Figure 5.23). Thus, also from the tip and the dwell step.
the combination of the DNR for the dose distribution If the patient can be reproducibly positioned on the
inside the target volume and the CI for the target cover- treatment table of both a CT scanner and a treatment
age are not suitable, easy to apply, evaluation tools for simulator, the localization of the target volume and crit-
HDR implants. ical organs can be obtained from the CT scans and the
Another index, based on the CDVHs of the target and localization of the catheters from two radiographs. The
critical structures, is the Conformal Index (COIN), intersection of the catheters reconstructed from radi-
which scores the target coverage together with the ographs can be displayed in the CT slices. In this way, any
unwanted irradiation of normal tissues and parts or all change in the patient localization between the CT ses-
of critical structures. (See reference 38 for an extensive sion and the simulator session can be visually detected
discussion.) and corrected interactively. This method is of interest for
HDR implants of the prostate.
Ultrasound imaging and three-dimensional treatment
planning tools have been used for evaluation of HDR
prostate implants [51]. The dosimetric quality indicators
5.8 THREE-DIMENSIONAL IMAGING
are the CI, the MPD, and the HI, which is the fraction of
TECHNIQUES
the target volume receiving doses in the range of 1.0-1.5
times the PD.
CT-based brachymerapy treatment planning is based on The combination of different imaging modalities in
the visualization of the tumor, the target volume, the the treatment of prostate carcinoma with HDR iridium-
catheters, and the surrounding anatomical structures in 192 afterloading is becoming common practice [46]. The
a series of two-dimensional CT slices or in three-dimen- flexible HDR catheters are inserted under guidance of
sional views reconstructed from these CT slices ultrasound imaging, but the treatment planning is per-
76 Computers in brachytherapy dosimetry

formed on the postneedle-placement CT images. The Monte Carlo simulation of the radiation transport equa-
target MPD is optimized to conform to the prostate's tion [47-50] and the convolution algorithms which are
peripheral shape as it changes from base to apex. The based on a scatter dose kernel calculated by Monte Carlo
urethra's dose is limited to 120% of the MPD. simulation [59]. An analytical approach is given by
MRI has excellent soft tissue imaging capabilities, but Daskalov et al [60].
the alinearities in the image prohibit direct utilization in The Monte Carlo aided three-dimensional dose calcu-
brachytherapy treatment planning. To get around this lations have become so accurate that they function as the
problem, the reconstruction of prostate implant standard against which other algorithms are compared.
catheters can be performed with radiography and the For example, recent data for the dose calculation around
imaging of the prostate and the implant can be done high dose-rate and pulsed dose-rate sources according to
with MRI [43]. In this paper, permanent seeds are the AAPM TG43 formalism are based on Monte Carlo
implanted, but the technique is equally valid for HDR calculations [9,10,11]. The convolution algorithms are
implants with catheters with X-ray rulers inserted for suitable for dose computations in heterogeneous geome-
radiography and MR rulers for MRI. With radiography, tries. They are similar in approach to the pencil beam
the seed coordinates are reconstructed in the conven- modeling of external beams, but are much more com-
tional manner from a pair of isocentric radiographs. The plex. Current treatment planning computers are not yet
reconstructed seed distributions are verified on the AP fast enough to use these algorithms for clinical treatment
and lateral radiographs. With MR scanning, a flat table planning. An overview of these algorithms is given by
top is used to allow reproducible patient positioning Williamson [59].
between MR scanning and radiography. After scaling of
the MR dataset to the real-size seed distribution, corre-
5.10 DOSE SUMMATION OF
sponding seeds in the data set of reconstructed seed
BRACHYTHERAPY AND EXTERNAL-BEAM
positions and signal voids in the MR images are interac-
DOSE DISTRIBUTIONS
tively identified. These corresponding seeds are distrib-
uted over a cranial, central, and caudal transverse slice
through the prostate. A total of about ten corresponding In order for doses from brachytherapy and external-
seeds is then used for matching with the corresponding beam treatments to be combined, both dose distribu-
signal voids in the MR images. The resulting rotation tions must be based on the same patient localization in
and translation to the MR images is then applied to all space. If the external beam and the brachytherapy treat-
reconstructed seeds. Similarly, instead of radiography, ment planning are both based on the same set of CT
CT imaging can be used for seed reconstruction, and slices, the overlaying is straightforward. If this is not the
image fusion is used for matching the MR images with case, common reference points in space must be defined
the CT ones [44]. for both modalities, or the brachytherapy patient orien-
Summarizing, three-dimensional imaging of a tation must be matched interactively to the external
brachytherapy implant is a valuable tool for reconstruc- beam one. Once the matching is obtained, the proper
tion of target and organs, and for assessment of the spatial transformations can be performed and the sum-
resulting dose distribution with the differential or nat- mation of the doses simply becomes an additive process.
ural DVH. The CDVHs of the target and of the critical Weighting factors based upon the biological effective-
organs show quantitatively the part of the target volume ness of each treatment modality must be applied. These
which is underdosed, and the amount of the critical weighting factors may be based upon radiobiological
organ volumes which are overdosed. CT imaging can models, such as the linear-quadratic (LQ) model [56].
also be used to reconstruct the localization of the This model can be used for high dose-rate, low dose-
catheters or even sources, but only if proper software is rate, and pulsed dose-rate treatments [57,58].
available. Finally, the dose distribution in transaxial The resulting dose distributions can be evaluated with
planes and even arbitrary user-defined planes can be dis- the viewing techniques available with current treatment
played together with the patient structures, interpolated planning systems. Three-dimensional isodose surfaces
between the CT slices. can be viewed together with the target and critical
anatomic structures [34]. For ease of viewing, the degree
of transparency and color of each of these isodose sur-
faces can be adjusted.
5.9 THREE-DIMENSIONAL DOSE
CALCULATION ALGORITHMS
5.11 RECENT DEVELOPMENTS IN
BRACHYTHERAPY
Three-dimensional dose algorithms which incorporate
the influence of tissue inhomogeneities and metal
shields on the dose distribution around brachytherapy With all the computing power, display techniques, and
sources are just emerging. Promising approaches are the optimization methods currently available, the degree to
Recent developments in brachytherapy 77

which a brachytherapy implant will be effective is deter- images are used to determine the catheters to be placed
mined not by how well the implant is optimized, but by through the template. Longitudinal ultrasound images
how well the physician has physically placed the are used to determine the depth of insertion. After the
catheters or applicators. Simply stated, optimization virtual catheters have been placed, the virtual dwell
software cannot provide a good dose distribution positions inside the target volume are activated by the
around a badly placed implant. Therefore, to assist in the planning system. Geometric optimization on volume is
correct implantation of the catheters or applicator, visu- currently available to obtain a real-time optimized dose
alization of the target volume, the critical structures, and distribution. Dwell positions and dwell weights can be
the catheters themselves is often essential. modified interactively to obtain the required dose spar-
When a CT scanner with a gantry tilt option is avail- ing of the urethra, e.g., to 120% of the MPD. In the live
able, a regular volume implant, such as a brain implant planning stage, the virtual catheters are replaced one by
using a template and needles, can be performed interac- one by the real inserted catheter. The real dwell posi-
tively, with each row of needles fully displayed in a CT tions are activated by the planning system and the dose
plane. distribution from the catheters already placed, and the
Filmless planning is the integration of the X-ray or virtual catheter left is displayed real time. In this way,
ultrasound imaging and the treatment planning deviations of the catheters from the planned position
process. In such an integrated brachytherapy unit, an and the corresponding deviation from the planned dose
isocentric radiographic localizer (such as a treatment distribution can be corrected with the catheters still to
simulator) with digital imaging capabilities is directly be placed. Finally, when all catheters have been placed
interfaced with the treatment planning computer. In and the dose distribution has been decided upon, the
the surgical theater, the localizer transfers on-line the actual treatment can start. Postplanning is done one or
image information to the treatment planning computer more days after the actual treatment has started, to
for reconstruction, optimization, and display of the check the stability of the catheter positions in the target
dose distribution. However, if these digital images are volume.
obtained from an image intensifier, they must be A full, real-time optimization method for volume
corrected for the image distortion due to the curved implants is still to be developed. Such a method should
surface of the image intensifier screen, the influence of combine the ease of the geometrical method (no dose
the earth magnetic field, and any imperfections of the points to be placed midway between the catheters) with
electro-optical system. As the required accuracy in the full optimization quality of the SSDS and should
reconstructing the catheters or sources is in the range allow one or more critical volumes inside and outside
of 0.5 mm, the distortion of a digital image must be the target organ to be treated to a predefined value of
corrected to the same extent. Such an integrated the PD. This is important for the HDR treatment of
brachytherapy system, which corrects these image dis- the prostate, where the urethra is to be treated to a
tortions to the required accuracy, is currently already given fraction of the PD and where the rectal wall
available [45]. This allows an interactive assessment of adjacent to the prostate is to be spared. Only when
a needle position during implantation, especially if, in such a fast volume optimization is available, will real-
the future, the localizer is also provided with a CT time full optimization of HDR volume implants
option for visualization of the target volume and the become possible.
surrounding structures. Considerable research is still to be conducted to
Three-dimensional ultrasound-guided perineal im- develop a bioeffect dose model that can be applied
plantation of the prostate, combined with real-time clinically. Computer software to implement such a
treatment planning using ultrasound images, is also model in a computer planning system is readily
becoming available [51]. Catheters, guided by a perineal available and will allow the display of radiobiological
template, are inserted into the prostate and connected to isoeffect distributions instead of physical isodose
an HDR afterloader. The three-dimensional ultrasound distributions.
unit provides real-time transverse and longitudinal slices
through the prostate and its immediate surroundings. A
longitudinal plane through the prostate and its sur-
roundings can be oriented such that a catheter being
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permanent 1-125 prostate implants using radiography and brachytherapy. In Brachytherapy from Radium to
and magnetic resonance imaging. Int.J. Radial Oncol. Optimization, ed. R.F. Mould, J.J. Battermann, A.A.
Biol. Phys., 37, 927-33. Martinezef al. Veenendaal, The Netherlands, Nucletron
44. Amdur R.J., Gladstone, D., Leopold, K.A. and Harris, R.D. International B.V., 39-48.
(1999) Prostate seed implant quality assessment using MR 58. Deehan, C. and O'Donoghue, J A (1994) Biological
and CT image fusion. Int.J. Radial Oncol. Biol. Phys., 43, equivalence of LDRand HDR brachytherapy. In
67-72. Brachytherapy from Radium to Optimization, ed. R.F.
45. Kolkman-Deurloo, I.K.K., Visser, A.G., Idzes, M.H.M. Mould, J.J. Battermann, A.A. Martinez etal.
and Levendag, P.C. (1997) Reconstruction accuracy Veenendaal, The Netherlands, Nucletron International
of a dedicated localiser for filmless planning in intra- B.V., 19-33.
operative brachytherapy. Radiother. Oncol., 44, 59. Williamson, J.F. (1995) Recent developments in basic
73-81. brachytherapy physics. In Radiation Therapy Physics, ed.
46. Mate, P.M., Gottesman, J.E., Hatton, J., Gribble, M. and A.R. Smith, Berlin, Springer Verlag, 247-302.
80 Computers in brachytherapy dosimetry

60. Daskalov, G.M., Kirov, A.S. and Williamson, J.F. (1998) Wijrdeman, H.K., Battermann, J.J. (2000) The combined
Analytical approach to heterogeneity correction factor use of the natural and the cumulative dose-volume
calculation for brachytherapy. Med. Phys., 25,722-35. histograms in planning and evaluation of permanent
61. Moerland, M.A., Van der Laarse, R., Luthmann, R.W., prostatic seed implants. Radiother. Oncol., 57,279-84.
6
Dose specification and reporting:the ICRU
recommendations

ANDRE WAMBERSIE AND JAN J.BATTERMANN

6.1 INTRODUCTION tons and electrons, the differences between the maxi-
mum and the minimum doses in the target volume often
reach 10%, 15%, and even 20%. Therefore, one can
This chapter addresses the problem of dose specification introduce large discrepancies, and thus confusion,
for reporting in brachytherapy. It is based on the recom- depending on the criteria (or the dose levels) used for
mendations of the International Commission on prescribing, recording, and reporting the treatment, e.g.,
Radiation Units and Measurements (ICRU), mainly maximum, minimum, or any mean dose or 'weighted'
ICRU Report 38, 'Dose and volume specification for mean dose. Such discrepancies are in general much
reporting intracavitary therapy in gynecology' (1985) larger than the current dosimetric uncertainties. On the
[ 1 ]1,and ICRU Report 58, 'Dose and volume specifica- other hand, a difference in dose of 5% can be detected
tion for reporting interstitial therapy' (1997) [2] 2 . clinically for some radical treatments [3,4].
Exchange of clinical information between radiation The ICRU recognized the importance of the problem
oncology centers requires uniformity and agreement on many years ago and, in 1978, published Report 29, 'Dose
the methods used to specify the doses and the volumes specification for reporting external beam therapy with
to which these doses are delivered. To avoid confusion, photons and electrons' [5]. This report was superseded,
an agreement has also to be reached on definitions of in 1993, by ICRU Report 50, 'Prescribing, recording and
the terms and concepts necessary for reporting treat- reporting photon beam therapy' [6]. A 'Supplement to
ments. ICRU Report 50' appeared recently [7].
Due to the limitations of the irradiation techniques, In brachytherapy, the situation is even more difficult
the doses delivered to the target volumes are in general because very high doses are always obtained close to the
not homogeneous. In external-beam therapy with pho- sources, and there are actually no large volumes for
which the dose is nearly homogeneous (reaches a kind of
plateau), as in external-beam therapy. The problem is
1. The Reporting Committee for ICRU Report 38 was the following: D
addressed in ICRU Reports 38 and 58. In order to retain
Chassagne and A Dutreix (Co-Chairmen), P Almond, JMV
Burgers, M Busch, and CA Joslin (Members), M Cohen and T
as much consistency as possible, it is desirable to use,
Landberg (Consultants). wherever possible, in the same terms and
2. The Reporting Committee for ICRU Report 58 was the following: D concepts and the same approach as in external-beam
Chassagne and A Dutreix (Co-Chairmen), D Ash, WF Hanson, AG therapy. In particular, the definitions of the volumes are
Visser and JF Wilson (Members). therefore the same for the two techniques. It is, however,
82 Dose specification and reporting: the ICRU recommendations

recognized that brachytherapy raises some specific prob- turized and highly flexible sources which can be used in
lems which have to be taken into account. afterloading devices with radionuclides of different
Other ICRU reports dealing with dose specification activities that can produce a wide range of dose rates. At
for reporting special techniques, such as electron, pro- the same time, sophisticated three-dimensional source
ton, and neutron beam therapy, are in preparation. localization methods have been developed and can be
For reporting in external-beam therapy, the dose is linked to computerized methods of dose calculation and
specified first at the ICRU reference point, which is representation of dose distribution. These developments
located (always) in the central part of the clinical target have led many clinicians to depart from the long-
volume, and (when possible) at, or near, the intersection established implant systems and it is for this reason that
of the beam axes. The maximum and the minimum a common language is valuable to provide a method of
doses to the planning target volume (or their best esti- dose specification for reporting which can be used and
mation) should also be reported. In brachytherapy, there be common for all types of brachytherapy applications.
are high dose gradients within the clinical target volume It should be stressed from the beginning that it has not
and the use of a single reference point is not, therefore, been the intention or the role of the ICRU to encourage
sufficient. It is, however, appropriate to consider the dose users to depart from their current practice of brachyther-
at points where plateaus of dose occur in the central part apy and from their method of dose prescription. The aim
of the clinical target volume and where the bulk of the of the ICRU recommendations is to develop a common
malignant cell population is generally located. This leads language for reporting a treatment, based on existing
to the concept of the mean central dose. concepts. The description of the treatment and the
In addition, the whole of the clinical target volume method of dose specification for reporting should be
must receive a certain minimum dose in order to achieve presented in a way that can be easily understood and
the desired clinical effect. It is therefore also important to closely related to the treatment outcome.
record the minimum dose at the periphery of the clini-
cal target volume, i.e., the minimum target dose.
Several systems of brachytherapy have developed his- 6.2 DEFINITION OF VOLUMES
torically. Best known and most widely used (with or
without modification) are the Manchester, Quimby and
The definition of volumes is of utmost importance, both
Paris systems [8-14].
in external-beam planning and in brachytherapy plan-
The term 'system' denotes a set of rules which takes
ning. The process of determining volumes for the treat-
into account the source types and strengths, geometry
ment of a malignant disease consists of several distinct
and method of application to obtain suitable dose distri-
steps, during which different volumes may be defined.
butions over the volume(s) to be treated. The system also
provides a means of calculating and specifying dose. It is
important to remember that, whereas an implant may 6.2.1 Gross tumor volume
follow the source distribution rules of a system, it does
not comply with the system unless the method of dose The gross tumor volume (GTV) is the gross palpable or
prescription and specification are also followed. In addi- visible/demonstrable extent and location of the malig-
tion, if the implant rules are modified, the dose unifor- nant growth.
mity intended by the system may be compromised. The GTV may consist of the primary tumor ('GTV
The situation is more difficult in intracavitary therapy primary'), metastatic lymphadenopathy(ies) ('GTV
due to the steep dose gradient in the vicinity of the nodal'), or other metastases. The GTV almost always
sources, i.e., throughout the target volume. Therefore, corresponds to those parts of the malignant growth
the specification of the target absorbed dose in terms of where the tumor density is largest. Due to the high den-
the absorbed dose at specific point(s), in the vicinity of sity of the cancer cells in the GTV, an adequate dose must
the sources, becomes less meaningful and a different be delivered to the whole GTV in order to achieve the
approach is required. Instead of a target-dose specifica- aim of therapy in radical treatments.
tion, a volume specification is an alternative and, in that According to the above definition, there is no GTV
respect, specification of an intracavitary application in after complete 'gross' surgical resection. There is no GTV
terms of the 'reference volume' enclosed by a reference when there are only a few individual cells or 'subclinical'
isodose surface of 60 Gy has been proposed in ICRU involvement (even histologically proven). From the ori-
Report 38. gin of medical terminology, the latin word tumor was
The problems of interstitial therapy (and of used to designate a swelling, which could be of various
brachytherapy in general) are discussed first. The specific types.
problems encountered in intracavitary therapy, and The shape, size, and location of the GTV may be
especially in gynecology, are dealt with in section 6.6. determined by means of different diagnostic methods
Over the last two decades, technological developments such as clinical examination (e.g., inspection, palpation,
in brachytherapy have seen the introduction of minia- endoscopy), and various imaging techniques (e.g., X-ray,
Definition of volumes 83

computerized tomography (CT), digital radiography, is still thought that radiotherapy is needed for the tissues
ultrasonography, magnetic resonance imaging (MRI), that remain close to the site of the removed GTV, this
and radionuclide methods). The methods used to deter- volume is also usually designated as CTV-T (e.g., in
mine the GTV should meet the requirements for scoring breast-saving procedures).
the tumor according to the TNM [15,16] and American Additional volumes with presumed subclinical spread
Joint Committee on Cancer (AJCCS) [17] systems, and (e.g., regional lymph nodes) may also be considered for
the definition of the GTV is then in full agreement with therapy. They are also defined as CTVs and may topo-
the criteria used for the TNM classification. graphically be designated CTV-N1, CTV-N2, etc.
The GTV (primary tumor, metastatic lymphadenopa- The CTV is a tissue volume that contains a gross
thy, other metastases) may appear to be different in size tumor volume and/or subclinical microscopic malignant
and shape, sometimes significantly, depending on what disease. This volume has to be treated at an adequate
examination technique is used for evaluation (e.g., pal- dose level (and time-dose pattern) in order to achieve
pation versus mammography for breast tumors, CT ver- the aim of therapy - cure or palliation.
sus MRI for some brain tumors). Therefore, the Delineation of a CTV will require consideration of
radiation oncologist should, in each case, indicate which factors such as the local invasive capacity of the tumor
method has been used for the evaluation and delineation and its potential to spread to, for example, regional
of the GTV. lymph nodes.
A GTV may be confined to only part of an organ (e.g., The CTV, like the GTV, is a purely clinical-anatomical
a Tl breast cancer), or involve a whole organ (e.g., mul- concept. It must always be described, independently of
tiple metastases of the brain). The GTV may or may not the dose distribution, in terms of the patient's anatomy
extend outside the normal borders of the organ tissue and the tumor volume. As a minimum recommenda-
involved. tion, the physical dimensions of the clinical target vol-
For reporting, the GTV should be described in stan- ume are described in terms of its maximum diameters
dard topographical or anatomical terms, e.g. '18 x 12 x (cm) in three orthogonal directions. For reporting, the
20 mm3 tumor in the left lobe of the prostate adjacent CTV must be defined in plain topographic terms and/or
but not reaching the capsule.' In many situations, a ver- according to a corresponding code in conformity with
bal description might be too cumbersome and, there- the recommendations for the GTV.
fore, for the purpose of data recording and analysis, a If different dose levels are prescribed, different CTVs
classification system is needed. Several systems are pro- have to be defined. This is the case, for example, in
posed for coding the anatomical description, some of 'boost' therapy where the 'high-dose' volume (often con-
them are mentioned in ICRU Report 50 [6]. taining the GTV) is located inside the 'low-dose' volume.
There are at least three reasons for identifying the It must be stressed that the descriptions of the GTV(s)
GTV. First, accurate description of the GTV is needed for and CTV(s) are based only on general oncological prin-
staging (e.g., TNM). Second, identification of the GTV is ciples, and are independent of any therapeutic approach.
necessary to allow for recording of tumor response in In particular, they are not specific to the field of radia-
relation to the dose and other relevant factors. It can be tion therapy. For example, in surgery, a safety margin is
used (carefully) as a prognostic factor. Third, an ade- taken around the GTV according to clinical judgement,
quate dose must be delivered to all parts of the GTV in and this implies the use of the same CTV concept as in
order to obtain local tumor control in radical treat- radiation therapy. In brachytherapy, as in external-beam
ments. therapy, volumes to be irradiated are defined, and thus
the same concept of CTV is applied. Furthermore, the
CTV concept can be applied to other modalities, e.g.,
6.2*2 Clinical target volume regional chemotherapy, hyperthermia, and photocoagu-
lation.
Clinical experience indicates that around a GTV there is The definitions of GTV and CTV in brachytherapy are
generally subclinical involvement, i.e., individual malig- thus identical to the definitions given for external-beam
nant cells, small cell clusters, or microextensions, which radiotherapy in ICRU Report 50 [6] and Supplement to
cannot be detected by the staging procedures. The GTV, Report 50, ICRU Report 62 [7].
together with this safety margin consisting of tissues
with presumed or proved subclinical involvement, is
defined as the clinical target volume (CTV). The tissues 6.2.3 Planning target volume
immediately surrounding the GTV usually have a high
malignant cell density close to the edge of the GTV; the In external-beam therapy, to ensure that all tissues
cell density decreases toward the periphery of the CTV included in the CTV receive the prescribed dose, one has,
(often a safety margin of about 1 cm thick is taken). This in principle, to plan to irradiate a volume geometrically
CTV is usually denoted CTV-T. larger than the CTV. This is the planning target volume
If the GTV has been removed by radical surgery, but it (PTV).
84 Dose specification and reporting: the ICRU recommendations

The additional safety margin included in the PTV 6.3 TECHNIQUES OF BRACHYTHERAPY:
results from a number of factors: CLASSICAL SYSTEMS
expected physiological movements (e.g., with respira-
tion) and variations in size, shape, and position (e.g., The Paterson-Parker or Manchester System was devel-
stomach, bladder, rectum) of the CTV; oped to deliver a reasonable dose uniformity (10%)
all variations and uncertainties in beam geometry and throughout a region implanted with radium needles
patient-beam positioning. [10].
The PTV is a geometrical concept, used for treatment The system specifies rules for the geometrical arrange-
planning, and it is defined to enable selection of appro- ment of the sources, and for the linear activity required
priate beam sizes and beam arrangements, taking into in order to cover a PTV with a sufficiently homogeneous
consideration the net effect of all the possible geometri- dose (Figure 6.1). The system includes tables of
cal variations, in order to ensure that the prescribed dose milligram-hour needed to deliver specified doses for dif-
is actually absorbed in the CTV. ferent sizes of implants or moulds. The proportion of
The dose distribution to the PTV has to be considered activity on the periphery is specified according to the size
to be representative of the dose distribution to the CTV. of the implant; it is larger for smaller implants. The
As indicated in ICRU Report 50 for external-beam system is still used for single-plane and double-plane
therapy, when delineating the PTV, consideration may implants in many centers.
also be given to the presence of any radiosensitive nor- The Quimby System is characterized by uniform
mal tissue (organs at risk) as well as to other factors such source spacing and uniform source activity [11].
as the general condition of the patient. Delineation of Consequently, this arrangement of sources resulted in a
the PTV is a matter of compromise, implying the judge- non-uniform dose distribution, higher in the central
ment and thus the responsibility of the radiation oncol- region of the implant (as in the Paris System; see Figure
ogist. 6.2). This system was particularly used in the US
In brachytherapy, the PTV is in general identical to the centers.
CTV. There are only very few exceptions. For instance, The Paris System of implant planning has been devel-
with some techniques in which there are uncertainties of oped mainly with iridium-192 wire sources [13,18]. The
consistency of source position (high dose rate, moving sources are of equal linear activity, parallel, placed at
sources, fractionated techniques) or alteration of equal distances, and arranged in such a way that their
source position (intracavitary applications, permanent centers are in the same plane perpendicular to the direc-
implants) during the application, the PTV may be larger tion of the lines (Figure 6.2a and b). This plane, called
than the CTV to take these factors into account. the central plane, is the midplane of the application
In this chapter, as in ICRU Report 58 [2], the term (Figure 6.3a, b, and c). If the volume to be treated is
clinical target volume is used rather than planning target large, more than one plane containing wires is used.
volume. Again, equidistance of the radioactive lines is required.
In external therapy, the two steps localization of CTV This means that their intersections with the central plane
and treatment planning can always be dissociated and are arranged according to the apices of equilateral trian-
therefore checked separately. However, in interstitial gles or squares (Figure 6.3b and 6.4a and b). This regu-
therapy, the CTV is finally decided upon by the clinician lar distribution of the wires results in a slight overdose at
at the time of implantation on the assumption that it is the center of the target volume. The dose rate at a point
contained within the minimum target isodose surface in the middle of a group of sources is called the basal
(see section 6.4.4). dose rate (BD). This BD is always calculated from the
This procedure cannot be recommended, and the position of the sources in the central plane and is the
CTV should be clearly described in the patient chart minimum dose rate between a pair or group of sources.
before the implant is planned. The values of the isodose curves are expressed as a per-
centage of the BD.
The reference dose rate is derived from the BD and is
6.2*4 Treated volume equal to 85% of the BD. It is used for calculating the total
treatment time of the implant.
The treated volume is that volume of tissue, based upon Because the ends of the active wires are not crossed, as
the implant as actually achieved, which will receive at in the Manchester System, the active sources should be
least a dose selected and specified by the radiation oncol- 20-30% longer than the target volume at both ends. The
ogist as being appropriate to achieve the purpose of minimum thickness of a treated volume is 50-60% of
treatment (e.g., tumor eradication or palliation). source separation for single planes and 130-150% for
The treated volume is thus encompassed by an isodose two planes.
surface corresponding to that dose level, which is the Dosimetry according to the Paris System has many
minimum target dose (see section 6.4.4). This isodose advantages. The use of equal linear activity, equal dis-
surface should, ideally, entirely encompass the CTV. tance between the sources, and the fact that no cross
Techniques of brachytherapy: classical systems 85

Figure 6.1 Manchester System for application of radioactive


sources with different loading. As an example, (a) is the
localization film for a bladder implant with radium needles of
different activity. Although the Manchester System was designed
for radium sources, it can be used with other radionuclides as
well, such as cesium-137 needles or iridium-192 wires.
As an example of the application of the Manchester System
with radioactive sources other than radium, (b) and (c) give the
distribution of dose rates for a single-pi one implant with
iridium wires of unequal linear activity in order to ensure dose
uniformity throughout the implanted region. Wires 1, 4, 5, and
6 (peripheral) contain a linear activity of 60 MBq (1.6 md) per
cm; wires 2 and 3 contain a linear activity of 37 MBq (1 md)
per cm. Wires 1, 2, 3, and 4 are 6 cm long; wires 5 and 6 are 3.5
cm long, (b) The dose rates in the plane containing the wires;
(c) the dose rates in a perpendicular plane.

needles are used make the application itself relatively the above-described techniques, because the isodose
easy. The relationship between the geometry of the lines generated by the computer allow a far more com-
implant, and the dimensions of the target volume can plete evaluation of the treatment plan. Both orthogonal
easily be determined. The dose rate can be quickly con- and isocentric techniques are used to reconstruct the
trolled with a planning computer, even in complicated source coordinates. The isocentric reconstruction
implantations. Nowadays, most of the implant tech- method is a variation of the stereo-shift method. With
niques are based on the original Paris System. isocentric equipment, like a treatment simulator, the
For rapid planning, in some institutes, normograms angle between the central axes of the projecting beams
have proven useful as approximate planning guides. Both can be enlarged up to 60, still obtaining two projections
for removable iridium implants and for permanent of the sources (carriers) on the same radiograph (Figure
iodine implants, normograms were developed at the 6.5 a, b, and c). With the simulator, variable angles can
Memorial Sloan Kettering Institute [19]. However, indi- also be chosen, such that sources are not obscuring one
vidualized computer planning, in general is superior to another.
86 Dose specification and reporting: the ICRU recommendations

Figure 6.2 lridium-192 wire implant according to the Paris System (single-plane implant). The wires are of equal linear activity,
parallel, and arranged in such a way that their centers are in the same plane perpendicular to the direction of the wires (i.e., the
central plane, see Figure 6.3).

Figure 6.3 Central plane. In an


implant where the source lines
are rectilinear, parallel, and of
equal length, the central plane
is perpendicular to the direction
of the source lines and passes
throughout their centers. The
mean central dose (DJ is the
arithmetic mean of the local
minimum doses D, (i = A, B ...)
in the plateau region, (a) A
single-plane implant; (b) a two-
plane implant; (c) an actual
single-plane implant where
sources are not rectilinear: the
central plane can be defined as
in (a). (From ICRU Report 58
[21)

6,4 DESCRIPTION OF DOSE DISTRIBUTION regions of high dose surrounding each source. However,
IN INTERSTITIAL THERAPY within the volume of the implant there are regions where
the dose gradient approximates a plateau (Figure 6.6).
6.4.1 General concepts 1. In an interstitial implant, the regions of plateau dose
are equidistant between adjacent neighboring
In interstitial therapy, the dose distribution is non- sources, for sources of identical activity. They are
homogeneous and includes steep dose gradients and regions of local minimum doses.
Description of dose distribution in interstitial therapy 87

Figure 6.4 Dose planning for implants with iridium-192 wires contained in two parallel planes, following the Paris System. Examples
of a breast implant in two planes, (a) The seven wires are equidistant and arranged in triangles (length of the wires 7 cm for the
upper row and 8 cm for the lower row), linear activity 52 MBq cnr1 (1.4 md cnr1), application time 43.32 h for a reference dose of
20 Gy. (b) The six wires are equidistant and arranged in squares (length of the wires 6 cm for the upper row and 7 cm for the lower
row), linear activity 52 MBq Cm-1 (1.4 mCi cm-1), application time 42.91 h for a reference does of 20 Gy.

2. Variations between these local minimum doses can In an actual implant, all source lines may not neces-
be used to describe the dose uniformity of an sarily be straight, parallel, and of equal length. In such
implant. cases, the central plane should be chosen perpendicular
3. A region of plateau dose is the place where the dose to the main direction of the source lines and passing
can be calculated most reproducibly and compared through the estimated center of the implant (see Figure
easily by different departments. 6.3c).
For more complex implants, it may be necessary to
Although in modern computer systems the three-
subdivide the target volume into two or more subvol-
dimensional dose distribution can be computed and pre-
umes for dose evaluation. In this event, a central plane
sented as isodose surfaces, these facilities are not yet
may be defined for each of these subvolumes (Figure
available in all departments.
6.7).
In order to provide the minimum of information
The calculation of dose distributions in multiple
needed about the dose or dose rate distribution, the cal-
planes throughout the target volume shows that a varia-
culation of isodose curves in at least one chosen plane is
tion of a few millimetres in the position of the central
necessary. If only one plane is chosen for isodose calcu-
plane is not critical.
lation, the central plane of the implant (as defined in sec-
tion 6.4.2) should be chosen for this purpose. In order to
assess the dose distribution in other areas of the implant,
6.43 Mean central dose
multiple planes for isodose calculation can be chosen,
either parallel or perpendicular to the central plane.
In interstitial therapy, the mean central dose is taken to
be the arithmetic mean of the local minimum doses
6.4.2 The central plane between sources in the central plane (or in the central
planes if there are more than one).
In source patterns in which the source lines are straight, In the case of a single-plane implant, the mean central
parallel, of equal length and with the centers which lie in dose is, in the central plane, the arithmetic mean of the
a plane perpendicular to the direction of the source lines, doses at mid-distance between each pair of adjacent
this plane is the central plane (see Figure 6.3a and b). source lines, taking into account the dose contribution at
88 Dose specification and reporting: the ICRU recommendations

Figure 6.5 Orthogonal AP (a), lateral (b) and isocentric (c)


radiographs of Fletcher-Suit rigid applicator. Note lead wire in
vaginal packing, contrast medium in balloon of Foley catheter,
and air in distal rectum.

that point from all sources in the pattern (see Figure


6.3a).
In the case of an implant with line sources in more than
one plane, the mean central dose is the arithmetic mean of
the local minimum doses between each set of three adja-
cent source lines within the source pattern (see Figure
6.3b). As seen in Figure 6.4a, the minimum dose lies at the
intersection of perpendicular bisectors of the sides of the
triangles (geometric center) formed by these source lines.
This point is equidistant from all three source lines.
In some complex implants, a single central plane may
not bisect or even include all the sources. In these cases,
a mean central dose based on one plane can be mislead-
ing and it is advisable to subdivide the volume and to
choose a separate central plane for each sub volume (see
Figure 6.7).
Figure 6.6 Plateau dose region between radioactive sources. In
Three practical methods are acceptable for determin-
a plane perpendicular to linear and parallel sources, the dose
ing the mean central dose:
distribution shows a plateau region of low dose gradient. In this
1. If parallel lines are used, one can identify triangles example of three sources, 6 cm long and with 1.5 cm spacing,
consisting of three adjacent source lines for all the the dose varies by less than 2% in the gray region between the
sources, so that the triangles formed constitute as sources. (From Dutreix et a I. [18].)
Description of dose distribution in interstitial therapy 89

Figure 6.7 Central planes in a complex implant. It is


sometimes necessary to plan the treatment in terms of two or
more subvolumes. In the example shown, where all source lines
are not of equal length, two central planes are identified: (a) for
the longest source lines and (b) for the shortest ones. Two mean
central doses are determined in the two subvolumes Dma and
Dmb, respectively. Open circles are the intersections of the sources
with the central planes, and closed circles are the points where
the local minimum doses are calculated. (From ICRU Report 58
[2].)

many acute triangles as possible. The intersection


points of the perpendicular bisectors of each triangle
are determined and the local minimum doses are
calculated at each of these points. The mean of these
local minimum doses is the mean central dose. This
method is the most precise one when parallel lines
are used.
2. Evaluation of dose profiles: the dose profiles are
calculated for one or more axes through the center
of the implant expected to pass through as many
local minima as possible. The local minimum doses
are determined by inspection. The mean of these
local minimum dose values is the mean central dose
(Figure 6.8). In a single surface implant performed
following a curved surface, a profile may lead to an
underestimation of the mean central dose. In a
complex implant, it may be difficult to find axes Figure 6.8 Evaluation of dose profiles. Three profiles (b) are
passing through the minima and profiles may lead to drawn along two orthogonal directions through a two-plane
an overestimation of the mean central dose. implant (a) with eight parallel line sources, 10 cm long, 1.8 cm
However, experience shows that the error lies within spacing. The profiles are calculated in percentage of the
acceptable limits. This method is sometimes minimum target dose (thick line) along axes XX, YY and YY in
preferred for seed implants. In a seed implant, such the central plane. The profile along the axis YY is the most
as the one presented in Figure 6.9, the dose should representative to estimate the mean central dose. The mean of
be calculated along several random profiles passing the local minimum doses is the mean central dose. The mean
through the implant. central dose is equal to 7 78% of the peripheral dose. (From
3. Inspection of dose distribution: the dose ICRU Report 58 [2].)
90 Dose specification and reporting: the ICRU recommendations

Figure 6.10 Determination of mean central dose from


inspection of dose distribution. Dose distribution in the central
plane of an implant with six parallel iridium-192 line sources,
6 cm long, 1.5 cm spacing, reference air kerma rate 14.5 mGyh-1
at 1 m. The dose varies by 5% between plotted isodose lines in
the region of interest. The idodose values are 16, 19, 22, 24, 26,
28, 30, 31.5, 33, 35, 40, and 45 cGy h-1 The local minima, A, B,
C, and D, can be easily estimated by inspection. DA and DD
approximate 31 cGy h-1 and D6 and Dc approximate 34 cGy h-1
The estimated mean central dose is Dm - 32.5 cGy h-1 (From
ICRU Report 58 [2].)

Figure 6.9 Seed implant with 68 iodine-125 seeds of 19.2 MBq


The minimum target dose is known in some
(0.52 md), total activity 1310 MBq (35.4 md). (a) Radiograph of
American centers as the 'minimum peripheral dose' [20].
implant, (b) Dose distribution in the central plane.
It is known as the 'reference dose' in the Paris System,
and is equal to about 90% of the prescribed dose in the
Manchester System for interstitial therapy.

distribution is plotted in the central plane. With


6.4.5 High-dose regions
isodose lines varying by 5% (at most 10%) of the
local dose in the central region, the local minima can
In order to correlate radiation dose with late damage, the
be determined by inspection. The mean of these
high-dose regions around sources should be assessed
local minima is the mean central dose (Figure 6.10).
(Figures 6.4 and 6.11).
This method is often preferred for complex implants
There will inevitably be a high-dose zone around each
with line sources.
source. Although this zone is often small and well toler-
ated, the exact tolerance dose and volume for interstitial
6*4.4 Minimum target dose therapy are not known. However, it is necessary, for
intercomparison purposes, to agree on a way to describe
The minimum target dose is the minimum dose at the the high-dose volumes. It has been suggested that a dose
periphery of the CTV. It should be equal to the mini- of approximately 100 Gy is likely to be significant in
mum dose decided upon by the clinician as adequate to determining late effects. In those patients who receive
treat the CTV. 50-60 Gy as peripheral minimum dose or 60-70 Gy as
The minimum target isodose surface is the isodose mean central dose, 100 Gy corresponds approximately to
surface corresponding to the minimum target dose. As 150% of the mean central dose. It is therefore recom-
indicated above, it defines the treated volume and should mended in ICRU Report 58 [2] to report the size of the
entirely encompass the CTV (see section 6.2.2). The region receiving more than 150% of the mean central
minimum target dose corresponds to the prescribed dose.
dose in many instances. The high-dose regions should be defined as the
Description of dose distribution in interstitial therapy 91

Figure 6.11 Tongue implant, using five loops of 8 cm indium


wires with activity of 68 MBq cm'1 (1.8 md cm-1).
(a) Radiographs of the implant, (b) Dose distribution in the
central plane of the implant.

regions encompassed by the isodose corresponding to Two parameters describing dose uniformity for inter-
150% of the mean central dose around the sources in any stitial implants are recommended in ICRU Report 58
plane parallel to the central plane where a high-dose [2]. They can be derived directly from the concepts of
region is suspected. The maximum dimensions of all minimum target dose and mean central dose:
regions in all planes calculated should be reported.
1. the spread in the individual minimum doses used to
calculate the mean central dose in the central plane
6.4.6 Low dose regions expressed as a percentage of the mean central dose;
2. the dose homogeneity index, denned as the ratio of
A low dose region should be defined as a region within minimum target dose to the mean central dose.
the CTV, encompassed by an isodose corresponding to
90% of the prescribed dose. The maximum dimension of
the low dose region in any plane calculated should be
6*4*8 Additional representations of the
reported.
dose distribution
In implants for which the CTV is included within the
In order to obtain a full perception of the dose dis-
minimum target dose isodose, the occurrence of a low
tribution of an implant, the use of volume-dose calcula-
dose region is exceptional. If the clinical target volume is
tions has been advocated (see, for example, references
not covered by the minimum target dose isodose, there
24-26).
will be low dose regions due to geographical miss.
For this purpose, the CTV (or a larger volume includ-
Low dose regions should be reported in order to cor-
ing an additional margin) is subdivided in subvolumes
relate the local recurrence rate with the dose distribu-
tion. (e.g., voxels) and the dose rate is calculated at the center
of each subvolume. The volume receiving at least a spec-
ified dose is then defined as the sum of all subvolumes
6*4.7 Dose uniformity parameters where at the center at least that dose is received.
Examples of results are shown in Figure 6.12. Because of
Several indices quantifying the homogeneity of the dose high dose gradients, significant differences in calculated
distribution have been proposed (see, for example, refer- volumes can be observed, depending upon the size of the
ences 21-23). elementary subvolumes. The size of the grid and of the
92 Dose specification and reporting: the ICRU recommendations

elementary subvolumes used in dose and volume calcu-


lations should be clearly stated.
Volume-dose data can also be represented by means
of histograms showing the distribution of fractions of
the CTV receiving doses within chosen intervals, espe-
cially the natural volume-dose histogram (NVDH) as
published by Anderson [27]. With this model, even small
differences between implants can be revealed. The main
characteristic of the NVDH is the peak that occurs with
regular implant of several sources (see, for example,
Figure 6.13). In fact, the peak dose reflects the basal dose
of the Paris System. If the implant is less uniform, the
peak is wider. So, the NVDH can be used for intercom-
parison between planned and realized source arrange-
ments [28,29].
The value of these alternative representations of the
dose distribution as a possible prognostic factor for
treatment outcome has still to be established in clinical
research.

6.5 RECORDING AND REPORTING


INTERSTITIAL THERAPY
Figure 6.12 Volume-dose curves. Volume (sum of subvolumes
receiving at least a certain dose) versus dose, for two different Adequate information must be recorded in order to give
patterns of parallel source lines: a two-plane implant with six a consistent description of any implant. The guidelines
sources 5 cm long (upper curve), and a cylindrical implant with for reporting doses will make it possible to compare
seven sources 4 cm long (lower curve). The dose is expressed as results of future brachytherapy practice and to better
percentage of the minimum target dose. The size of the voxel relate outcome to treatment. In order to report an
used for calculation is 1 mm3. For the upper curve, linear implant, at least the following should be recorded [2].
sources are simulated by point sources (seeds) arranged in a
linear fashion. (Bridier et al. [25])

Figure 6.13 Natural volume-


dose histogram of the tongue
implant in Figure 6.11.
Treatment dose rate of 1 Gy h-1
was chosen to deliver 60 Gy in
60 h. (From Anderson [27].)
Recording and reporting interstitial therapy 93

6.5.1 Description of volumes 6.5.4 Description of time-dose pattern

The description of volumes should include as a mini- The description of the time-dose pattern should include
mum the GTV, the CTV, and the treated volume. the type of irradiation with the necessary data on treat-
ment and irradiation time, as described below. The infor-
mation on dose and time should provide the necessary
data to calculate instantaneous and average dose rates.
6.5.2 Description of sources Continuous irradiation: the overall treatment time
should be recorded.
The description of the sources employed should include Non-continuous irradiation: both the overall
details of: treatment time and the total irradiation time should
be recorded.
Radionudide used including nitration, if relevant.
Fractionated, hyperfractionated, and pulsed
Type of source used, i.e., wire, seed, seed ribbon,
irradiation: the irradiation time of each fraction, the
hairpin, needle, etc.
interval between fractions, and the overall treatment
Length of each source line used.
time should be recorded.
Reference air kerma rate of each source (or source line):
When the irradiation times of the different sources
the reference air kerma rate of a brachytherapy source
are not identical, they should be recorded.
is the kerma rate to air, in air, at a reference distance of
1 m, corrected for air attenuation and scattering. The Moving sources:
quantity reference air kerma rate is expressed in Gy s-1 Stepping sources: step size and dwell time should be
at 1 m, or a multiple of this unit (in a convenient way, recorded if constant. Variation of the dwell times of a
for low dose-rate brachytherapy, in microgray per stepping source can be used for manipulating the dose
hour, )m,Gy Ir1, at 1 m). distribution. If such a dose optimization is applied,
The problem of specification of sources used in this should be specified (e.g., optimization on dose
brachytherapy has been discussed by several authors, points defined in the implant or geometrical
and the quantity reference air kerma rate has been optimization [42].
increasingly adopted by different organizations or Oscillating sources: speed in different sections of the
commissions [1,2,30-39]. vectors should be recorded.
The distribution of the strength within the source
should be described (uniform or differential loading, 6.5.5 Total reference air kerma (IRAK)
etc.) [40,41].
The total reference air kerma is the sum of the products
of the reference air kerma rate and the irradiation time
for each source.
6.5.3 Description of technique and The TRAK is an important quantity which should be
source pattern reported for all brachytherapy applications. It is a quan-
tity that is simple to calculate and on which there can be
If the source distribution rules of a standard system have no ambiguity. It is analogous to the milligrairrhour
been followed, this must be specified. If it is not the case, (mg.h) of radium. The conversion of the quantity mg.h
the source pattern should be described completely and to the TRAK is easy and straightforward (1 mg.h radium
unambiguously. equivalent corresponds to 7.2 mGy h-1, at 1 m).
In addition, the following data should be recorded: In addition, the TRAK is proportional to the integral
dose to the patient, and can also serve as a useful index
number of sources or source lines, for radiation protection of personnel. However, the sim-
separation between source lines and between planes, ple determination of the TRAK does not allow one to
geometrical pattern formed by the sources with the derive, even approximately, the absorbed dose in the
central plane of implant (e.g., triangles, squares), immediate vicinity of the sources (i.e., in the tumor or
where relevant, target volume).
the surfaces in which the implant lies, i.e., planes or
curved surfaces,
6.5.6 Description of dose distribution
whether crossing sources are placed at one or more
ends of a group of linear sources,
The following doses should be recorded.
the material of the inactive vector used to carry the
radioactive sources, if any (e.g., flexible or rigid); Prescribed dose: if the dose is not prescribed at the
whether rigid templates are used at one or both ends, level of either the minimum target dose or the mean
type of remote afterloading, if used. central dose, the method of dose prescription should
94 Dose specification and reporting: the ICRU recommendations

be recorded. If, for clinical or technical reasons, the point(s), in the vicinity of the sources, is not at all mean-
dose received differs from the prescribed dose, it ingful and a different approach is required. Instead of a
should be noted. target-dose specification, a volume specification is rec-
Minimum target dose. ommended in ICRU Report 38 [1].
Mean central dose. Specification of an intracavitary application in terms
of the 'reference volume' enclosed by the reference iso-
The following additional information, when available,
dose surface of 60 Gy is proposed. However, as the dif-
should be recorded:
ferent isodose surfaces are close to each other, the
Dimension of high dose region(s). indication of the reference volume must be supple-
Dimension of any low dose region. mented, for safety reasons, by the indication of the
Any dose uniformity data. TRAK. In addition, recording the absorbed dose at refer-
Additional representation of dose distribution, if any. ence points related to organs at risk or to fixed bony
structures is recommended.
The above guidelines are based on the recommenda-
As for interstitial therapy, the ICRU recommendations
tions contained in ICRU Report 58 [2]. It should be
contained in Report 38 [1] do not imply a modification
stressed again that it is not the intention, or the role, of
of the method used for the calculation of the treatment
the ICRU to encourage radiation oncologists to depart
duration, but they require the calculation of specific
from their current practice of dose prescription or tech-
quantities for reporting.
nique of application.
The recommendations presented in ICRU Report 38
The ICRU reports aim to help radiation oncologists to
[1] must be considered a minimum requirement for
report a given application in the same way, using the
reporting. On the other hand, the reported parameters
same definitions and concepts. One should avoid a situ-
will be meaningful only to the extent that the technique
ation in which the same application would be described
of the particular intracavitary application has been com-
differently in different centers or, conversely, in which
pletely described.
the same reported dose would correspond to completely
ICRU Report 38 [1] deals mainly with the treatment
different actual dose distributions.
of cervix carcinoma, for which the anatomical region of
For the purposes of this chapter, the prescribed dose is
interest is similar for every patient and the possible vari-
defined as the dose which the physician intends to give
ation in the position of the radioactive sources is limited.
and which is entered in the patient's treatment chart.
However, for other gynecological intracavitary applica-
Depending on the system used, the approach for dose
tions, the same philosophy can be adopted, but some of
prescription in interstitial therapy may be different from
the numerical values and definitions may need to be
center to center.
modified according to the type of application.

6.6 SPECIFIC PROBLEMS FOR 6.6.2 Description of the technique


INTRACAVITARY THERAPY IN GYNECOLOGY
It is recommended that the technique be described on
the basis of the guidance given below.
6.6.1 Introduction
THE SOURCES
As the absorbed dose in soft tissues from intracavitary
applications is so highly non-uniform throughout the 1. Radionuclide
target volume, the concepts of maximum, mean, 2. Reference air kerma rates
median, and modal target absorbed dose, as defined in 3. Shape, filtration, etc.
ICRU Report 50 [2], are not relevant. The minimum tar-
get absorbed dose is the only useful concept and is, by SIMULATION OF LINEAR SOURCES
definition, equal to the treatment absorbed dose level.
When a linear source is simulated by a set of point
For external-beam therapy, it has been recommended
sources, the activity of these point sources and their sep-
that the target absorbed dose be defined as the absorbed
aration^) must be indicated [25,43].
dose at one or more specification points which are rep-
When moving sources are used to simulate a set of dif-
resentative of the dose distribution throughout the tar-
ferent sources in fixed position, in order to produce an
get volume. These specification points could be
appropriate dose distribution, the following indications
established with respect to the target volume (center or
are required [44-47]:
central part) or to the beam axes, or both.
In contrast, in intracavitary therapy, due to the steep 1. type of movement (continuous or stepwise, step
dose gradient in the vicinity of the sources, i.e., through- distance),
out the target volume, the specification of the target 2. unidirectional or oscillating movement,
absorbed dose in terms of the absorbed dose at specific 3. range of movement or oscillation,
Specific problems for intracavitary therapy in gynecology 95

4. speed in different sections of the applicator, or dwell rates, the radiation oncologist has to indicate the dose
times of the source at different positions. level which he or she believes to be equivalent to 60 Gy
delivered at the conventional low dose rate, and this
THE APPLICATOR should be clearly stated [48-50].
Reference to the applicator is sufficient when a complete Reference volume: description of the pear-shaped
description has already been published, provided that there volume
is no significant difference between the applicator used and When the uterine source(s) is combined with vaginal
the one described in the literature. To avoid confusion, it is sources, or when the uterine source is more heavily
recommended that the applicator be described, including loaded at the lower end, the tissue volume to be
the name of the manufacturer. The description should described presents a pear shape, with its longest axis
include information on the following points: coincident with the intrauterine source (Figure 6.14).
This reference volume is defined by means of three
1. rigid (or not), consequently with fixed known
dimensions (Figure 6.15):
geometry (or not) of the complete applicator,
2. rigid uterine source with fixed curvature (or not), 1. the height (dh)is the maximum dimension along the
3. connection between vaginal and uterine applicators, intrauterine source and is measured in the oblique
i.e., fixed, loose (semi-fixed), free, frontal plane containing the intrauterine source;
4. type of vaginal sources, number and orientation of 2. the width (dw) is the maximum dimension
line sources, special sources (box, ring, etc.), perpendicular to the intrauterine source and is
5. high atomic number shielding materials in vaginal measured in the same oblique frontal plane;
applicator (or not). 3. the thickness (dt) is the maximum dimension
perpendicular to the intrauterine source and is
measured in the oblique sagittal plane containing the
6.63 Recommendations for reporting intrauterine source.

Three sets of quantities are recommended in ICRU The definitions of dh, dw and dt are proposed in order to
Report 38 [1] to specify intracavitary application for minimize the number of calculations. These dimensions
cervix carcinoma; they complement each other and are usually expressed in centimeters. The volume esti-
should be combined. mated from the intersections of the surface of a pear-
shaped volume on two conventional planes does not
TOTAL REFERENCE AIR KERMA (TRAK)
necessarily represent the size of the true reference vol-
ume. However, for most applications they do not differ
The TRACK will always be reported (see section 6.5.5). from the maximum dimensions of the reference volume
by more than 1 or 2 mm.
DESCRIPTION OF THE REFERENCE VOLUME
ABSORBED DOSE AT REFERENCE POINTS
The description of the reference volume, i.e., the tissue
volume encompassed by a reference isodose surface, has Several reference points are in current use. Some are rel-
been proposed for specification in reporting. The rea- atively close to the sources and related either to the
sons for this approach are described in section 6.6.1. sources or to organs at risk; others are relatively far from
the sources and are related to bony structures. The fol-
Dose level
lowing definitions apply to the case where the doses are
An absorbed dose level of 60 Gy is widely accepted as the
calculated from two perpendicular radiographs, anterio-
appropriate reference level for conventional low dose-
posterior (AP) and lateral. When other methods are
rate therapy. When two or more intracavitary applica-
used, such as stereographic X-ray films, oblique perpen-
tions are performed, the absorbed dose to consider is
dicular radiographs or transverse sections (CT scans),
that resulting from all applications. The time-dose
the calculations need to be modified.
pattern should be clearly stated.
When intracavitary therapy is combined with Reference points close to the sources and related to
external-beam therapy, the isodose level to be considered the sources
is the difference between 60 Gy and the dose delivered at As such points are located in a region where the dose
the same location by external-beam therapy. For exam- gradients are high, any inaccuracy in the determination
ple, if a dose of 20 Gy were delivered to the whole pelvis of distance results in large uncertainties in the absorbed
by external-beam therapy, the isodose level to be consid- doses evaluated at these points. Such calculated absorbed
ered would be 60 20 Gy = 40 Gy. Nevertheless, it is rec- doses do not, therefore, seem an appropriate means of
ognized that the combined dose does not necessarily characterizing an intracavitary application and/or of
produce the same effect as a similar dose from intracav- reporting the target absorbed dose, particularly if rigid
itary therapy alone. source combinations are not used. Such points are not
For intracavitary therapy at medium or high dose recommended in ICRU Report 38 [ 1 ].
96 Dose specification and reporting: the ICRU recommendations

Figure 6.14 Dose distribution


of Fletcher-Suit rigid
applicator, as in Figure 6.5,
using total activity of 606 MBq
(16.4 md) cesium-137 and
showing the pear-shaped tissue
volume, (a) Plane
perpendicular to Z-axis. (b)
Plane perpendicular to X-axis.

Reference points relatively close to the sources but downwards to bring the balloon against the urethra.
related to organs at risk On the lateral radiograph, the reference point is
The determination and specification of the absorbed obtained on an AP line drawn through the center of
dose to organs at risk (bladder, rectum, etc.) are obvi- the balloon. The reference point is taken on this line at
ously useful with respect to normal tissue tolerance lim- the posterior surface of the balloon. On the frontal
its. However, such information will be meaningful only radiograph, the reference point is taken at the center
to the extent that it is obtained and expressed in precise of the balloon.
and well-codified ways. The point of reference for the rectal dose is obtained
as follows. On the lateral radiograph, an AP line is
Calculated values: reference points for the expression drawn from the lower end of the intrauterine source
of the absorbed dose to the bladder and the absorbed (or from the middle of the intravaginal sources). The
dose to the rectum (see Figure 6.16) have been point is located on this line 5 mm behind the
proposed by Chassagne and Horiot [51]. posterior vaginal wall. The posterior vaginal wall is
The bladder reference point is obtained as follows. A visualized, depending upon the technique, by means
Foley catheter is used. The balloon must be filled with of an intravaginal mould or by an opacification of the
7 cm3 of radio-opaque fluid. The catheter is pulled vaginal cavity with a radio-opaque gauze used for the
Specific problems for intracavitary therapy in gynecology 97

Figure 6.16 Determination of the reference points for bladder


and rectum as proposed by Chassagne and Horiot [51].)

Reference points related to bony structures


The lymphatic trapezoid is obtained as follows (Figure
6.18). A line is drawn from the junction of S1-S2 to
the top of the symphysis. Then a line is drawn from
the middle of that line to the middle of the anterior
aspect of L4. A trapezoid is constructed in a plane
passing through the transverse line in the pelvic brim
plane and the midpoint of the anterior aspect of the
Figure 6.15 Geometry for measurement of the size of the pear- body of L4 (from Fletcher [52]).
shaped 60 Gy isodose surface (broken line) in a typical treatment A point 6 cm lateral to the midline at the inferior
of cervix carcinoma using one rod-shaped uterine applicator end of this figure is used to give an estimate of the
and two vaginal applicators. Plane a is the 'oblique'frontal dose rate to mid-external iliac lymph nodes.
plane that contains the intrauterine device. The oblique frontal At the top of the trapezoid, points 2 cm lateral to
plane is obtained by rotation of the frontal plane around a the midline at the level of L4 are used to estimate the
transverse axis. Plane b is the 'oblique' sagittal plane that dose to the low para-aortic area.
contains the intrauterine device. The oblique sagittal plane is The midpoint of a line connecting these two points
obtained by rotation of the sagittal plane around the AP axis. is used to estimate the dose to the low common iliac
The height (d J and the width (d J of the reference volume are lymph nodes.
measured in plane a as the maximal sizes parallel and The pelvic-wall reference point [51] can be visualized
perpendicular to the uterine applicator respectively. The on an AP and a lateral radiograph and related to fixed
thickness (dt) of the reference volume is measured in plane b as bony structures. This point is intended to be
the maximal size perpendicular to the uterine applicator. (From representative of the absorbed dose at the distal part
ICRU Report 38 [1].) of the parametrium and at the obturator lymph nodes
(Figure 6.19). On an AP radiograph, the pelvic-wall
reference point is intersected by the following two
lines: a horizontal line tangential to the highest point
packing. On the AP radiograph, this reference point is
of the acetabulum, and a vertical line tangential to the
at the lower end of the intrauterine source or at the
inner aspect of the acetabulum. On a lateral
middle of the intravaginal source(s).
radiograph, the highest points of the right and left
Monitoring of the absorbed dose rate to the rectum: in
acetabulum, in the cranio-caudal direction, are joined
addition to calculating the rectal dose, the dose, or
and the lateral projection of the pelvic-wall reference
dose rate, can be measured at different points along
point is located at the mid-distance of these points.
the anterior rectal wall to ensure that no area of the
rectal mucosa receives a dose above the tolerance Evaluation of the absorbed dose at reference points,
level. This type of measurement requires special care related to well-defined bony structures and lymph node
in positioning the measuring probe. An example is areas, is particularly useful when intracavitary therapy is
given in Figure 6.17. combined with external-beam therapy. It is also useful in
98 Dose specification and reporting: the ICRU recommendations

Figure 6.17 Measurement of the rectal dose rate. The rectal dose
is measured following the insertion of the source applicators,
either preloaded (low-activity treatment) or manually loaded with
low-activity sources identical in design to those used during high-
activity afterloaded treatment. Method A: the measuring probe is
moved relative to a rigid guide tube inserted into the rectum and
held in position. The point of maximum rectal dose rate is noted
and the distance d, in cm, from the anal verge deduced. Method
B: the measuring probe is moved so that the tip of the probe is
moved along the midline of the recto-vaginal septum until the
point of maximum dose rate is reached. Distance is taken as a
direct reading on the central tube and at the anal verge. The dose
rate and distance are recorded.
The major disadvantage of Method A is that the probe tip
cannot follow the surface of the anterior rectal wall closely.
However, a IIowa nee for the distance of the probe sensor from the
vagi no-recta I septum needs to be taken into account. (From ICRU
Report 38 [1].)

Figure 6.18 Determination of


the lymphatic trapezoid. On the
left is an anteroposterior view
and on the right a lateral view
(see text). (From Fletcher [52].)

helping to avoid an overdose when intracavitary therapy The respective planes for which the dose distribution
is to be followed by surgery. is to be computed will depend on the technique and the
particular clinical situation. However, as a minimum
requirement, it is recommended that the dose distribu-
CALCULATION OF DOSE DISTRIBUTION
tions be computed in two planes: the oblique frontal
The present recommendations, in particular the descrip- plane and the oblique sagittal plane, both containing the
tion of the reference volume encompassed by the 60-Gy intrauterine source.
isodose surface, necessitate the computation of complete When practicable, it is recommended that dose distri-
dose distributions in several planes. butions be calculated in additional sets of planes and
Concluding remarks 99

Figure 6.19 Determination of


the right (RPW) and left (LPW)
pelvic wall reference points (see
text). (From Chassagne and Horiot
[57].;

that these dosimetric data be correlated with those calculated isodose surfaces can be obtained for given
obtained from radiographs or CT sections, in order to loadings of the applicator. Therefore, pre-calculated
determine the absorbed dose at any relevant anatomical dimensions of height, width, and thickness can be
point. given [53].
While this additional information will be of value in Uterine packing in endometrial carcinoma. In
assessing effects in any individual patient, it will also connection with uterine packing, the same definitions
provide: of height, width and thickness given in section 6.6.3
can be used. However, two facts need to be noted:
1. the possibility of comparing the methods of
specification used in different centers and of width and thickness are usually located at the level of
evaluating their respective merits; uterine fundus (the pear-shaped volume is
2. the possibility of comparing the methods of reversed),
specification used in historical series (mgh, points height should be determined in the oblique frontal
'A' and 'B') with the methods recommended in ICRU plane, which gives the maximum dimension.
Report 38 [1];
3. the possibility of deriving new clinical and
radiobiological data and correlations which could 6.7 CONCLUDING REMARKS
improve treatment techniques and develop further
the method of specification.
At the end of this chapter, it should be stressed again that
the aim of the ICRU Reports 38 and 58 [1,2] is not to
6.6*4 Definition of the 60-Gy reference encourage the users to depart from their current practice
volume in special situations in brachytherapy. Treatment prescription is the respon-
sibility of the radiation oncologist (or team) in charge of
One linear source only. In some situations, only one the patient; it is based on the radiation oncologist's
linear source is present: judgement and experience and implies his or her respon-
sibility.
in the case of a narrow vagina with a uterine source
Reporting a treatment is another issue. The aim of the
protruding into the vaginal cavity,
ICRU efforts is to recommend a common language for
in the case of vaginal irradiation with a central source
reporting a treatment in such a way that the clinical
from a cylindrical applicator.
information can be exchanged in a relevant way, avoid-
In estimating the volume in this simple case, the ing misinterpretation and confusion between radiation
width is equal to the thickness, as the dose oncologists and departments.
distribution is symmetrical about the source axis. However, the use of the same sets of definitions, con-
Vaginal sources only. When only vaginal sources are cepts, and approaches for prescribing, recording, and
present, width is the largest dimension from right to reporting a treatment has obvious advantages in simpli-
left in an oblique frontal plane through the main axis fying the issues and avoiding confusion. It could be a
of the vagina. long term beneficial consequence of the ICRU efforts.
Thickness is the largest dimension in a direction ICRU Report 58 [2] on interstitial brachytherapy was
perpendicular to the above oblique plane. Height is published at the end of 1997, but Report 38 [ 1 ] was pub-
measured along the vaginal axis, and is commonly lished in 1985. Significant changes took place during the
shorter than the other two dimensions. 14 years in the field of brachytherapy, especially the
Rigid applicator. Provided that there is a fixed development and dissemination of high dose-rate, and
connection between vaginal and uterine sources, pre- pulse dose-rate applications.
100 Dose specification and reporting: the ICRU recommendations

Revision of ICRU Report 38 [1] becomes necessary As in external-beam therapy, the limits between the
and is welcomed by the radiation oncology community, three levels proposed for reporting in brachytherapy are
as indicated by a recent inquiry [54,55]. The ICRU initi- not definitely fixed, but may vary, in time, with the devel-
ated a revision of Report 38, in 1998, on the basis of the opment of the imaging, computation, and dosimetry
answers to a questionnaire sent to the ESTRO members techniques.
and a large survey of the recent literature. The following
topics are considered: HDR, MDR, PDR, exploitation of
the patient data provided by the modern imaging tech-
REFERENCES
niques, localization of the different Volumes', and identi-
fication of the organs at risk, specification of dose,
combination of external and intracavitary therapy, 1. International Commission on Radiation Units and
three-dimensional treatment planning, and radiobiolog- Measurements (1985) Dose and Volume Specification for
ical issues raised by the different dose rates which can Reporting Intracavitary Therapy in Gynecology, ICRU
now be applied. Report 38,7910 Woodmont Avenue, Bethesda, Maryland
The use of the TRAK should be encouraged. The fact 20814, USA.
that several companies use this quantity to specify the 2. International Commission on Radiation Units and
sources they are manufacturing will certainly facilitate its Measurements (1997) Doseand Volume Specification for
general use (e.g., Amersham,1 CIS Bioindustries,2 Reporting Interstitial Therapy, ICRU Report 58,7910
Mallinckrodt Medical3). Woodmont Avenue, Bethesda, Maryland 20814, USA.
Finally, as in externa-beam therapy (see ICRU Report 3. International Commission on Radiation Units and
50 [6]), several levels of complexity could be proposed Measurements (1976) Determination of Absorbed Dose in
for reporting the treatments in brachytherapy (see, for a Patient Irradiated by Beams of X or Gamma Rays in
example, reference 56): Radiotherapy Procedures, ICRU Report 24,7910
Woodmont Avenue, Bethesda, Maryland 20814, USA.
Level 1: basic techniques-minimum requirements. A
4. Mijnheer, B.J., Battermann, JJ. and Wambersie, A. (1987)
standard applicator is used, with a fixed geometry.
What degree of accuracy is required and can be achieved
Unambiguous and simple definitions of reference
in photon and neutron therapy? Radiother. Oncol., 8,
points are required. Radiographs are taken to check
237-52.
the position of the applicator.
5. International Commission on Radiation Units and
Level 2: advanced techniques-modern radiotherapy
Measurements (1978) Dose Specification for Reporting
standards. An individual assessment of absorbed
External Beam Therapy with Photons and Electrons, ICRU
doses at reference points, in different volumes (GTV,
Report 29,7910 Woodmont Avenue, Bethesda, Maryland
CTV, PTV), organs at risk, and normal anatomy is
20814, USA.
needed, based on radiographs taken in well-defined
6. International Commission on Radiation Units and
geometry or CT sections. Computer-assisted dose
Measurements (1993) Prescribing, Recording and
calculations are performed in three planes at different
Reporting Photon Beam Therapy, ICRU Report 50,7910
levels/sections, indicating accurately the doses at the
Woodmont Avenue, Bethesda, Maryland 20814, USA.
chosen reference points, reference volume(s), and
7. International Commission on Radiation Units and
other volumes of interest, e.g., high dose volumes.
Measurements (1999) Prescribing, Recording and
Level 3: developmental techniques-clinical research.
Reporting Photon Beam Therapy (Supplement to ICRU
Planning and performance of brachytherapy
Report 50), ICRU Report 62,7910 Woodmont Avenue,
according to proposed level 3 imply individualized
Bethesda, Maryland 20814, USA.
three-dimensional, computer-assisted assessment of
8. Paterson, R. and Parker, H.M. (1934) A dosage system for
the patient anatomy based on sectional imaging (e.g.,
gamma ray therapy. Br.J. Radio!., VII, 592.
with CT, MRI, ultrasound). The different volumes,
9. Paterson, R. and Parker, H.M. (1952) A dosage system for
such as GTV, CTV, PTV, and organs at risk, can be
interstitial radium therapy. Br.J. Radiol., 25,505-16.
identified and localized. This makes possible accurate
10. Meredith, W.J. (1967) Radium Dosage: the Manchester
three-dimensional dose computation at selected
System. Edinburgh, Livingstone.
reference points and in different volumes of interest.
11. Quimby, E.H. and Castro, V. (1953) The calculation of
Dose-volume histograms can also be computed.
dosage in interstitial radium therapy. Am.J. Roentgenol.,
70,739-49.
12. Pierquin, B. (1964) Precis de Curietherapie,
1. Amersham International pic, Amersham Laboratories, White Lion
Road, Amersham, Buckinghamshire HP7 9LL, UK. EndocurietherapieetPlesiocurietherapie. Paris, Masson.
2. CIS Bioindustries (Compagnie ORIS Industrie S.A.), CEN Saclay, 13. Pierquin, B., Dutreix, A., Paine, C, Chassagne, D.,
91190 Gif-sur-Yvette, France. Marinello, G. and Ash, D. (1978) The Paris System in
3. Mallinckrodt Medical B.V., Westduinweg 3, NL-1755 LE Petten, interstitial radiation therapy. Acta Radiol. Oncol., 17,
The Netherlands. 33^7.
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14. Pierquin, B., Wilson, J.F. and Chassagne, D. (1987) Modern 31. Dutreix, A. and Wambersie, A. (1975) Specification of
Brachytherapy, Masson, New York. gamma-ray brachytherapy sources. Br.J. Radiol.,48,1034.
15. International Union Against Cancer (1997) TNM 32. Comite Francais de Mesure des Rayonnements lonisants
Classification of Malignant Tumours, 5th edn, ed. L.H. (1983) Recommendations pour la Determination des Doses
Sobin and C.H. Wittekind. New York, Wiley-Liss and Sons. Absorbeesen Curietherapie, Rapport du Comite Francais
16. International Union Against Cancer (1990) TNM Atlas, 'Mesure des Rayonnements lonisants' No. 1. Paris, Bureau
Illustrated Guide to the TNM/pTNM, Classification of National de Metrologie.
malignant tumours, 3rd edn, ed. 0. Spiessl et al. Berlin, 33. BCRU (1984) Specification of brachytherapy sources,
Springer Verlag. Memorandum from the British Committee on Radiation
17. American Joint Committee on Cancer (1988) Manual for Units and Measurements. Br.J. Radiol., 57,941-2.
Stagingof Cancer, 3rd edn, ed. O.H. Beahrs, D. Henson, 34. AAPM (1987) Specification of Brachytherapy Source
R.V.P. Mutter and M.H. Myers. Philadelphia, J.P. Lippincott. Strength, AAPM Report No. 21. New York, American
18. Dutreix, A., Marinello, G. and Wambersie, A. (1982) Institute of Physics.
Dosimetrieen Curietherapie. Paris, Masson. 35. Netherlands Commission on Radiation Dosimetry (1991)
19. Anderson, LL, Hilaris, B.S. and Wagner, LK. (1995) A Recommendations for Dosimetry and Quality Control of
normograph for planar implant-planning. Radioactive Sources used in Brachytherapy, NCS Report 4,
Endocuriether./Hypertherm. Oncol., 1,9-15. Netherlands Commission on Radiation Dosimetry,
20. AAPM (1993) Remote Afterloading Technology, AAPM Bilthoven.
Report No. 41. New York, American Institute of Physics. 36. British Institute of Radiology (1993) Recommendations for
21. Wu, A., Ulin, K. and Sternick, E.S. (1988) A dose Brachytherapy Dosimetry. Report of a Joint Working Party
homogeneity index for evaluating 192-lr interstitial of the BIR and the IPSM. London, British Institute of
implants. Med. Phys.,15,104-7. Radiology.
22. Paul, J.M., Koch, R.F. and Philip, PC. (1988) Uniform 37. Nath, R., Anderson, LL, Luxton, G., Weaver, K.A.,
analysis of dose distribution in interstitial brachytherapy Williamson, J.F. and Meigooni, A.S. (1995) Dosimetry of
dosimetry systems. Radiother. Oncol., 13,105-25. interstitial brachytherapy sources: recommendations of
23. Saw, C.B. and Suntharalingam, N. (1991) Quantitative the AAPM Radiation Therapy Committee Task Group No.
assessment of interstitial implants. Int.J. Radial Oncol. 43. Med. Phys., 22,209-34.
Biol.Phys., 20,135-139. 38. Societe Francaise des Physiciens d'Hopital (1995) Controle
24. Neblett, D., Nisar Syed, A.M., Puthawala, A.A., Harrop, R., de Qua lite en Curietherapie par lridium-192 a Haul Debit
Frey, H.S. and Hogan, S.E. (1985) An interstitial implant deDose, Rapport No. 11, Commission de Curietherapie,
technique evaluated by contiguous volume analysis. Institut Curie, 26 rue d'Ulm, 75231 Paris Cedex.
Hypertherm. Oncol., 1,213-21. 39. International Commission on Radiation Units and
25. Bridier, A., Kafrouni, H., Houlard, J.P. and Dutreix, A. Measurements (1970) Specification of High Activity
(1988) Comparison des distributions de dose en Gamma-ray Sources, ICRU Report 18,7910 Woodmont
curietherapie interstitielle autour des sources continues Avenue, Bethesda, Maryland 20814, USA.
et discontinues. International Symposium on Dosimetry 40. Bernard, M., Guille, B. and Duvalet, G. (1975) Mesure du
in Radiotherapy, IAEA SM-298/23, IAEA, Vienna. debit d'exposition lineique nominal des sources a une
26. McCrae, D., Rodgers, J. and Dritschilo, A. (1987) Dose- dimension, utiliseesen curietherapie./ Radiol. Electrol.,
volume and complication in interstitial implants for 56,785-90.
breast carcinoma. Int.J. Radial Oncol. Biol. Phys., 13, 41. Ling, C.C. and Gromadski, Z.C. (1981) Activity uniformity
525-9. of 192lrseeds. Int.J. Radial Oncol. Biol. Phys., 7,665-9.
27. Anderson, LL (1986) A 'natural' volume-dose histogram 42. Kolkman-Deurloo, I.K.K., Visser, A.G., Niel, C.G.J.H, Driver,
for brachytherapy. Med. Phys., 13,898-903. N. and Levendag, P.C. (1994) Optimization of interstitial
28. Laarse, R. van der and Prins, T.P.E. (1994) Comparing the volume implants. Radioth. Oncol., 31,229-39.
Stepping Source Dosimetry System and the Paris System 43. Dutreix, A. and Wambersie, A. (1968) Etude de la
using volume-dose histograms of breast implants. In repartition des doses autour de sources ponctuelles
Brachytherapy from Radium to Optimization, ed. R.F. alignees. Acta Radiol., 7,389--tOO.
Mould, J.J. Battermann,A.A. Martinez and B.L Speiser. 44. Henschke, U.K., Hilaris, B.S. and Mahan, G.D. (1966)
Veenendaal, The Netherlands, Nucletron, 352-72. Intracavitary radiation therapy of cancer of the uterine
29. Merrick, G.S., Butler, W.M., Dorsey, A.T., and Walbert, H.L cervix by remote afterloading with cycling sources. Am. J.
(1997) Prostaticconformal brachytherapy: 125l/103Pd Roentgenol.,96,45.
postoperative dosimetric analysis. Radial Oncol. Invest., 45. Joslin, C.A., Liversage, W.E. and Ramsay, N.W. (1969) High
5,305-13. dose-rate treatment moulds by afterloading techniques.
30. National Council on Radiation Protection and Br.J. Radiol.,42,108.
Measurements (1974) Specification of Gamma-ray 46. Joslin, C.A., Smith, C.W. and Mallik, A. (1972) The
Brachytherapy Sources, NCRP Report 41,7910 Woodmont treatment of cervix cancer using high activity 60-Co
Avenue, Bethesda, Maryland 20814, USA. sources., Br. J. Radiol., 45,257.
102 Dose specification and reporting: the ICRU recommendations

47. von Essen, C.F. (1980) Clinical application of the uterine cervix. In Textbook of Radiotherapy, ed. G.H.
Brachytron: the San Diego technique for treatment of Fletcher. Philadelphia, Lea & Febiger, 720-851.
cancer of the cervix. In High Dose-rate Afterloading in the 53. International Atomic Energy Agency (1972) Atlas of
Treatment of Cancer of the Uterus, ed. T.D. Bates and R.J. Radiation Dose Distributions, Vol. IV, Brachytherapy
Berry. British Journal of Radiology Special Report 17, Isodose Charts. Sealed Radium Sources, ed. M. Stovall, L.H.
p. 117. Lanzl and W.S. Moos. Vienna, International Atomic Energy
48. Hall, E.J. (1994) Radiobiologyfor the Radiologist, Agency, Vienna.
Philadelphia, J.B. Lippincott Company. 54. Groupe Europeen de Curietherapie-European Society for
49. van Limbergen, E., Chassagne, D. Gerbaulet, A. and Haie, Therapeutic Radiology and Oncology (1998) Workshop
C. (1985) Different dose rates in preoperative ICRU 38: The basis for a revision (Dir. R. Potter), Napoli,
endocavitary brachytherapy for cervical carcinoma./ Eur. 11-13 May.
Radiother., 1,21-7. 55. Potter, R., van Limbergen, E., Gerstner, N. and Wambersie,
50. Leborgne, F., Fowler, J.F., Leborgne, J.H., Zubizaretta, E. A. (2000) Survey of the use of the ICRU 38 in recording and
and Chappell, R. (1997) Biologically effective doses in reporting in brachytherapy of cervical cancer. Radiother.
medium dose rate brachytherapy of cancer of the cervix. Oncol.
Radial Oncol. Invest., 5,289-99. 56. Potter, R., Kovacs, G. and Haverkamp, U. (1995) 3D
51. Chassagne, D. and Horiot, J.C. (1977) Propositions pour Conformal Therapy in Brachytherapy, 8th International
une definition commune des points de reference en Brachytherapy Conference, Nice (France), 25-28
curietherapiegynecologique.y. Radiol. Electrol., 58,371. November 1995, Nucletron-Oldelft, PO Box 930,3900 AX
52. Fletcher, G.H. (1980) Squamous cell carcinoma of the Veenendaal, The Netherlands.
7
Afterloading systems

A. FLYNN

7,1 INTRODUCTION apy equipment are mentioned, this should not be taken
to imply any specific recommendation of the products of
any individual company. The chapter does not make rec-
The aim of this chapter is to examine the various after- ommendations of the merits and demerits of similar
loading systems that are currently available and also some treatment machines made by the different manufactur-
that are perhaps not strictly currently available but have ers. The reader will appreciate that machines which are
been used in the recent past. It is not intended to be a com- similar (but not identical) in their mode of operation are
plete itemization of the subject, but rather an overview of available from different manufacturers and suppliers: an
the main types of equipment and the uses to which they example of such a pair of similar machines is the
are generally put. It is anticipated that this chapter will microSelectron-HDR (supplied by Nucletron) and the
help the newcomer to this field to see which systems are Varisource (supplied by Varian). It is the responsibility of
particularly suited to each treatment site and method of the prospective purchaser to decide which particular
treatment. It is inevitable in an analysis of this nature that machine of a certain type is best suited to his or her pur-
there will be omissions, as it is impossible to cover every pose, bearing in mind the cost, safety aspects, supplier's
aspect of each use of each piece of equipment or tech- service record, and all other appropriate considerations.
nique, and the writer apologizes in advance to any user of The reader is referred to Chapter 1 for further details
this equipment if his or her particular technique has been of the radioactive sources associated with these after-
omitted. However, it is hoped that there is sufficient infor- loading techniques, and to Chapters 8 and 9 for a full
mation for a user or potential user to perceive the relative discussion of commissioning and quality assurance
clinical and technical advantages and disadvantages of aspects of low, high, and pulsed dose-rate equipment. An
each method or equipment. No attempt has been made to excellent review of remote afterloading technology may
assess the relative costs of the equipment, as this will vary be found in American Association of Physicists in
from one country to another depending on the local sup- Medicine (AAPM) Report No. 41 [1], and internation-
ply situation and servicing and delivery costs. However, it ally agreed specifications for the safety requirements of
will become apparent that some types of equipment are remotely controlled afterloading equipment may be
designed to be specific for a particular site in the body, found in reference 2.
whereas others are more flexible in the way that they can
be adapted for use in several body sites, and the financial
considerations of whether a particular machine will be
7.2 ADVANTAGES OF AFTERLOADING
more or less cost-effective will depend, in part, on the
anticipated number of applications and the case mix.
It is stated at the outset that, whilst various suppliers The accelerated development of afterloading from the
of radioactive sources and manufacturers of brachyther- 1960s onwards was initially driven by the desire to
104 Afterloading systems

improve the radiation protection environment of the oscillating source positions has been dependent on the
staff involved in the provision of brachytherapy treat- availability of computer-controlled, accurate source
ments. Readers of older textbooks will find pictures of positioning, which would not be possible without after-
implants using many radium needles, all of which were loading.
inserted manually in the operating theatre, with the con-
sequent radiation exposure of the clinicians and other
staff, and there are both documented and anecdotal 73 DEFINITION OF LOW, MEDIUM, HIGH,
reports of radiation injury to the fingers of radiothera- AND PULSED DOSE RATES
pists.
The technique of afterloading involves the placing of
There is no general agreement in the literature regarding
the non-radioactive needles, tubing, or applicators into
the boundaries between low, medium, and high dose rate
the patient without the presence of the radioactive
or even where the relevant dose rates are defined. Both
sources. Often, dosimetry radiography will be performed
the International Commission for Radiological Units
at this stage using non-radioactive marker inserts in the
(ICRU) [3] and the AAPM [1] base their definitions on
applicators. The radioactive material is inserted only
the dose rate at the prescription point or prescription
when all of the preliminary procedures have been carried
isodose. ICRU 38 is a document concerned solely with
out and the operator is satisfied that the applicators are
intracavitary therapy, so it may be reasonably assumed
placed correctly within the treatment site. In the case of
that it refers to the dose rate at or near point A of the
manual afterloading, the sources are introduced into the
Manchester System, but a similar inference cannot be
carrier needles or tubing directly by the operator, using
made for the AAPM categories. The ICRU recognizes
forceps or other appropriate manipulation instruments.
three categories:
This may be done in the operating theatre (for example,
in the case of iridium-192 hairpins) or perhaps on the Low dose rate (LDR): 0.4 Gy Ir1 to 2 Gy Ir1
ward (as may be the case for cesium-137 gynecological Medium dose rate (MDR): 2 Gy Ir1 to 12 Gy Ir1
source trains or iridium-192 wires). In this way, the radi- High dose rate (HDR): greater than 0.2 Gy mhr1
ation exposure to operating room and radiography staff (i.e., 12Gyh-')
may be minimized. An important 'by-product' of the use although it acknowledges that these definitions are
of non-radioactive materials at this stage is that the debatable.
radiotherapist is able to spend more time in the placing On the other hand, the AAPM defines LDR in terms of
of the applicators and can therefore obtain an improved '... conventional doses of about 10 Gy are delivered daily
geometry within the implant site. Thus, afterloading ...,' which implies a prescription dose rate of about
confers a benefit to the patient, even with this minimal 0.5 Gy Ir1. An HDR category is defined as having a pre-
afterloading method. scription dose rate greater than 0.2 Gy min~', which is the
However, it is apparent that with manual afterloading same as the ICRU definition of HDR. MDR is defined as
the radiation protection advantage is gained only in the being 'between LDR and HDR,' but the boundary
initial phases of the treatment and that, eventually, the between LDR and MDR is not defined. It is interesting
sources themselves have to be inserted into the applica- that the dose rate of about 1.5 Gy Ir1 that has been fre-
tors by the operator and the patient has to be cared for quently used for cervix treatment since afterloading was
by the nursing and clinical staff, with radioactive sources introduced, and for which radiobiological considera-
in position, for the duration of the treatment. The use of tions require a dose rate correction factor to be used, is
remote or machine afterloading extends the radiation actually less than the lower boundary for MDR as
protection advantage to the whole of the brachytherapy defined by the ICRU, and is therefore regarded as LDR by
treatment in that not only are the sources placed initially this authority, although it could be classed as MDR
in the applicators by the machine, but they may also be according to the AAPM definitions. However, this dose
temporarily withdrawn from the patient into the rate is often colloquially called MDR.
machine's protected safe for the duration of any nursing Another definition may arise from the standpoint of
procedures that the patient may require. In addition,.the radiation protection, where the interest is in the envi-
treatment machine timer(s) controls the duration of the ronmental levels of radiation around equipment rather
treatment to a high degree of accuracy. than the clinical dose rates. For example, the Guidance
Whereas considerations of radiation protection were Notes for the United Kingdom's Ionising Radiation
the main driving force for the development of afterload- Regulations [4] defines equipment giving a dose rate of
ing, more recently other advantages have become appar- less than 10 m Gy h-1 at 1 m as LDR; radiation levels
ent. For example, high dose-rate (HDR) and pulsed greater than this are HDR. This boundary corresponds
dose-rate (PDR) brachytherapy would not be possible approximately to a dose rate at point A of 0.4 Gy mur1,
(or would at least be highly inconvenient) without the which is not the same as the ICRU and AAPM boundary.
use of afterloading devices. Also, the modern develop- In practice, these differences are somewhat academic,
ment of conformal brachytherapy using stepping or as HDR machines generally operate at dose rates well
Manual afterloading systems 105

above these boundaries, typically at around 2 Gy mhr1, The implantation of the carrier tubing into the treat-
which is well within the HDR category as denned by all ment site may be performed either with flexible nylon
the aforementioned documents. The boundary between tubing or with rigid needles, depending upon the cir-
LDR and MDR is more questionable. In any event, the cumstances of the particular case. Surgical methods of
only safe practice when reporting radiotherapy is to state placing the tubing in the implant site have been
exactly the dose, dose rate, and fractionation used, as described by Pierquin et al. [9]. The encapsulated irid-
recommended in the ICRU Report 38 [3]. ium wires are held in place for the duration of the
The idea behind pulsed dose-rate (PDR) brachyther- implant by crimped lead discs separated from the
apy is to replace continuous low dose-rate brachytherapy patient's skin by nylon balls. These may be easily
(CLDR) by a series of 'pulses' of higher dose-rate treat- removed to allow removal of the wires from the patient
ment. Brenner and Hall [5] and Fowler and Mount [6] at the end of treatment. The main problem with the use
have published analyses of studies of the radiobiology of of these flexible tubes is that it is difficult to achieve good
these modalities, from which come recommendations implant geometry, as the tubes do not generally remain
that, to obtain equivalence to CLDR, the PDR should straight in the patient. The use of rigid needles (and,
give the same overall dose in the same overall time, pro- where possible, templates) permits improved implant
vided that the pulse interval is about 1 h, the length of geometry: this method is preferred where possible.
each pulse should be not less than 10 min, and each
pulse should give a dose of about 0.5 Gy, i.e., a dose rate
7.4.2 Iridium hairpins
of not more than about 3 Gy h-1 within the pulse. Some
early studies of the use of PDR have been reported [7,8].
These have a larger diameter than the wires and are
The main advantage of PDR is technical, in that it
therefore more rigid. The overall diameter is 0.6 mm,
enables the equivalent of CLDR to be given with a single
this being made up of a 0.4 mm diameter central 'core' of
stepping source, thereby increasing the range of active
iridium/platinum alloy, surrounded by a platinum
lengths and dose distributions that may be obtained.
sheath of thickness 0.1 mm. They are available in a pre-
formed 'hairpin' shape, as shown in Figure 7.1. The
length of each 'leg' of a hairpin is 60 mm, and this may
7A MANUAL AFTERLOADING SYSTEMS be cut down to the required length just prior to implan-
tation. Single pins may be available to special order.
Hairpins are implanted into the tissue with the aid of
7.4.1 Iridium wires
slotted hairpin guides. The guides are implanted and
their positions checked by radiography. If they appear
Iridium wire has an external diameter of 0.3 mm and is
satisfactory, the hairpins are inserted into the guides,
generally supplied as a loosely wound coil containing a
which are then removed, leaving the hairpins in the tis-
length of 500 mm, although other lengths may be avail-
sue. These are secured by a suture around the crosspiece
able to special order. In cross-section there is a central
of the hairpin.
'core' of iridium/platimim alloy of diameter 0.1 mm,
which is surrounded by a sheath of platinum of thick-
ness 0.1 mm, giving the overall diameter of 0.3 mm, as
stated above. It is available in a range of activities; for
further details, the reader is referred to Chapter 1.
In use, the wire is cut to the appropriate lengths
required for the particular application. Before being
afterloaded into the needles or 'outer' tubing implanted
in the patient, it is normal practice for the wire itself to
be encapsulated into the so-called 'inner' tubing. Once
the wire has been fed into its encapsulating tubing, the
latter is deformed slightly, either mechanically (for
example by the Amersham crimping tool or the
Amersham Iridium Wire Loader crimping tool) or by
heat (for example, by the now obsolete TEM Iridium
Wire Loader), to provide a seal in the tubing at each end
of the wire which fixes the wire into the tubing. Non-
active ends of empty tubing may be left at each end of
the wire and these may be used to control the position of
the active material within the 'outer' tubing or needles.
Equipment to facilitate the preparation of iridium wires Figure 7.1 Indium wire hairpin (courtesy Nycomed-Amersham
is commercially available. pk).
106 Afterloading systems

Hairpins are particularly useful in head and neck the Manchester ovoids), but they are cylindrical in shape
implants where the implant site is often only accessible and incorporate tungsten rectal and bladder shielding.
from one end. The radioactive 'bridge' across the top of The colpostats are linked external to the patient and may
the hairpin provides an effective 'crossing source,' which move with a 'scissor' action to allow the separation
allows the reference isodose to be brought up to the level between them to be varied.
of the mucosa. A further modification was reported and evaluated in
1985 [ 14] to enable the applicator system to be used with
the Selectron-LDR afterloading unit.
7*43 Iridium ribbons

In North America, iridium-192 is available in the form of 7*4*7 Amersham Gynecological System
'ribbons.' A ribbon consists of 12 seeds loaded into a
nylon carrier, the seeds being placed at 10 mm intervals. A manual afterloading system is supplied by Nycomed-
They are used in a similar way to iridium wires in that Amersham. The applicators are based on the Manchester
the ribbon is afterloaded into previously positioned car- System and are designed to allow the ovoids to be sepa-
rier tubing in the implant site. The ribbon may be short- rated by a 'washer' or 'spacer' or be used 'in tandem.'
ened to the required active length by cutting between the There is a choice of three sizes of applicators. The appli-
seeds. One advantage over conventional wire is that it cators are made of semi-flexible plastic tubing and are
becomes unnecessary to cut through the active material supplied pre-sterilized and are intended to be disposed of
itself when preparing the sources. Otherwise, the after a single use. The uterine tube and ovoids are linked
method of use is similar to that for the iridium wires together, but they can slide longitudinally with respect to
already described. one another to accommodate differing anatomy. In con-
trast to the traditional Manchester System, the ovoids lie
with their axes parallel to the vaginal axis.
7.4*4 Iodine seeds
The source trains used with these applicators consist
of a flexible helical spring, which is loaded with an
Iodine seeds are mainly used for non-afterloaded tech-
arrangement of miniature cesium-137 sources and spac-
niques and are therefore beyond the scope of this chap-
ers. A number of standard source train arrangements are
ter. Examples of their use are for transperineal
available and, if required, the supplier can make up
implantation of the prostate, which has been described
trains to the customer's requirements at the time of pur-
by Blasko et al. [10], and for the manufacture of oph-
chase. Normally, therefore, a selection of trains would be
thalmic applicators. However, the treatment of brain
needed to cover the variations in source requirements
lesions using removable afterloaded high activity seeds
envisaged. The handle of each source train is marked
has also been described [11].
with a code to aid identification, as shown in Figure 1.2
in Chapter 1. Figure 7.2 shows a typical applicator set.
7*4*5 Tantalum wire Other applicators are available based on the Fletcher and
the Henschke systems, but these use the standard
This material was similar in construction to iridium cesium-137 tubes. This system is described in more
wire, which has now superseded it, owing to the latter's detail in Chapter 1.
greater specific activity. It was used in the late 1940s and
early 1950s as a source for interstitial implants.

7*4*6 Fletcher-Suit applicators

These applicators for treatment of the uterine cervix


developed from a non-afterloading system designed by
Fletcher [12] and modified in the early 1960s by Suit
[13]. Suit's modification allowed the use of afterloaded
radium sources, now superseded by cesium-137 sources,
held in a hinged carrier, which could be inserted into the
tubes. The source arrangement has similarities to the tra-
ditional Manchester System (see Chapter 4) in that it
employs a line source in the uterine canal and two vagi-
nal sources, one placed in each lateral fornix. In the
Fletcher-Suit system, the vaginal sources are called 'col- Figure 7.2 Amersham manual afterloading system for the
postats' rather than 'ovoids.' There are three sizes of col- uterine cervix; plastic applicator set (courtesy Nycomed-
postat, 20 mm, 25 mm, and 30 mm diameter (similar to Amersham pic).
Lose dose-rate remote systems 107

7.5 LOW DOSE-RATE REMOTE SYSTEMS 7.5.2 Selectron-LDR/MDR

Whilst a number of types of afterloading machines pre-


The reasons behind the introduction of remote after-
date the Selectron-LDR (Nucletron), it could be argued
loading systems are considered in section 7.2. However,
that this machine was the first LDR afterloading machine
it will also be apparent from the foregoing descriptions
to achieve worldwide acceptance. It was developed by
of manual afterloading systems using pre-prepared
Nucletron during the late 1970s and has been in exten-
source trains that another significant disadvantage to
sive clinical use since around 1980. There are over 100
this method is the limited availability of source arrange-
installations around the world and the reader will find
ments. An institution would generally have only a small
numerous references in the literature relating to its clin-
number of source trains, which limits the number of
ical use. It was designed initially for the treatment of the
applicator combinations and dose distributions that may
uterine cervix [16], but it has also been used for intra-
be employed. Remote afterloaders were therefore
luminal and surface applicator treatments.
designed to attempt to overcome this restriction by
The Selectron-LDR was designed to circumvent the
increasing the number of available source patterns. In
aforementioned difficulty by allowing the user the flexi-
earlier machines, this was done by having a larger num-
bility of being able to construct source trains as required
ber of preloaded trains, whereas later machines allow the
for a particular insertion. To this end, it contains up to 48
user to compose source trains in the required pattern at
cesium-137 sources of external diameter 2.5 mm (see
the time of use, or by using a single source whose move-
Figure 1.3 in Chapter 1) and a large number of inactive
ment through the applicators can be controlled to give
spacers, also of diameter 2.5 mm. The sources and spac-
the desired dose distribution.
ers are initially stored in their respective compartments of
This section reviews some of the LDR afterloaders and
the main safe. When a source train is programmed and
their applications.
composed by the user, the machine selects sources and
spacers in the correct order, as required, and places them
in a vertical column in the so-called 'intermediate safe.'
7.5.1 Curietron Three-channel and six-channel versions of the machine
are available, so this process is repeated until all the
The Curietron is one of the older type of afterloaders. It required channels have been prepared. When all channels
was designed and manufactured in France and was used have been composed, they may be pneumatically driven
during the 1960s and 1970s, though it is now largely through flexible transfer tubes into the treatment appli-
obsolete. The machine was used for the treatment of the cators. The trains may be withdrawn into the intermedi-
uterine cervix. It employed pre-loaded flexible source ate safe during planned treatment interruptions, under
trains, consisting of cesium-137 sources and spacers in alarm conditions, and finally at the end of the treatment.
various combinations. The trains were mechanically Each channel may be independently timed.
coupled to drive motors and up to three trains could be Source activities between 20 mCi (740 MBq) and
transferred to the patient applicators. The treatment 40 mCi (1480 MBq) are available. Most users opt for the
exposure of each train could be independently timed higher activity sources, which typically give a dose rate to
and the treatment could be readily interrupted to allow the Manchester Point A of about 1.5-1.7 Gy tr1, putting
for nursing care. The treatment unit contained a safe for it in what might be called the MDR category.
the source trains, to which they were withdrawn during The gynecological applicators are constructed of stain-
interruptions and at the end of the treatment. less steel, the tubing being 6 mm external diameter. They
The capacity of the main treatment unit was limited are available in various configurations, including the
to four source trains, so the Curietron also had a 'sec- Manchester set, the Fletcher set (which incorporates
ondary' radiation sources safe, separate from the main shielding in the ovoids), the Henschke set, and a ring appli-
treatment unit, which housed extra source trains, cator set in which the vaginal component is in the form of
thereby increasing the range of treatment dose distribu- a ring of sources around the cervical os. There are also
tions that could be obtained. When the applicators and applicators for vaginal and endometrial treatments. The
treatment requirements for a particular application open ends of the applicators are mechanically coded to
were known, the appropriate source trains were trans- ensure that they connect to the correct transfer tubes.
ferred to the main treatment unit, from whence they The Selectron-LDR has also been used for the treat-
were subsequently driven into the applicators, as ment of the oesophagus [17] and nasopharynx [18].
described above.
The radioactive sources were cesium-137 pellets of
length 5.3 mm and diameter 1.8 mm. These were loaded 7.5.3 microSelectron-LDR
into source holders, with spacers, to give a variety of
active lengths. The use of this machine is described in High dose-rate afterloaders have now mainly superseded
reference 15. this machine. It is an LDR system that can position
108 Afterloading systems

radioactive sources into up to 18 treatment catheters 7.6 HIGH DOSE-RATE SYSTEMS


simultaneously, and has been typically used for LDR
implant therapy. The catheters have an external diameter
of 2 mm and may be either flexible tubes or rigid nee- High dose-rate afterloading has become increasingly
dles. Flexible transfer tubes connect the catheters to the popular in recent years. The main advantage is the
treatment unit. As with most other afterloaders, each increased rate at which treatments can be carried out,
catheter may be timed independently. which is particularly important when a high patient
A choice of source systems is available. Originally, the throughput is required. Treatment may be given in min-
microSelectron-LDR was used with iridium wires. utes instead of several hours or days, and may be given
These were made from the standard coils of iridium on a day-case basis in many instances. The short treat-
wire (as described in section 7.4.1) and had to be made ment times allow rigid rectal retractors to be used,
up to the required lengths and attached to the drive thereby reducing the rectal dose compared with LDR
cables, using a preparation station supplied with the systems. However, these advantages must be offset to
machine. A range of lengths would be made up to some extent by the fact that the treatment has to be frac-
ensure that wires suitable for any proposed treatments tionated, so a patient may need several of these, albeit
were available. The treatment unit itself could store up shorter, treatments within a course of treatment. Also,
to 18 wires; any further lengths were stored in a sepa- there may be a clinical disadvantage in that a patient may
rate sources safe, from where they could be transferred need several anesthetic episodes during the course of
to the treatment unit when required, in a manner rem- treatment, depending on the insertion procedure being
iniscent of the Curietron. The main disadvantage of performed. Also, the treatment rooms required for HDR
these was the short half-life of iridium-192, which equipment need to be more substantial than for LDR
meant that new sources had to be prepared every few equipment, due to the extra radiation protection
weeks. Later, miniature cesium-137 source trains were required, making HDR installations generally more
introduced, which overcame this disadvantage. expensive.
Reference 19 describes an example of the use of this Reference is made in the clinical sections of this book
system. to some of the treatment regimes used in HDR
brachytherapy; these, of course, are very different from
those used for the equivalent LDR therapy due to radio-
7*5.4 Buchler System biological considerations. Now that much experience has
been gained in the clinical applications of HDR therapy,
This machine has been used in both low dose-rate and most new installations of afterloading equipment are of
high dose-rate versions, and in single-channel and three- this type. The reader is referred to a recently published
channel configurations, and is intended principally for report of the AAPM Task Group 59, which considered
the treatment of the uterine cervix. It uses either cesium - the practice of HDR afterloading brachytherapy [20].
137 or iridium-192 sources. Each channel is treated by a
single source, rather than a train of sources as used in the 7.6.1 TEMCathetron
machines described above. All sources are mechanically
afterloaded, but the central source of a three-channel Although most of these machines have now been de-
unit (or the only source of a single-channel unit) is commissioned, the Cathetron is discussed here as it was
mechanically coupled to a drive system which controls the first HDR afterloader to be put into general use, par-
the position of the source in an oscillating manner ticularly for the treatment of the uterine cervix, and con-
within its catheter, the range and pattern of movement of siderable valuable data regarding treatment schedules for
the source being used to provide the required dose dis- this condition were obtained using this machine. It was
tributions. An eccentric cam within the drive system, the introduced in 1966 and its early clinical use is described
shape of which determines the position of the source at by O'Connell et al. [21]. It consisted essentially of a
any instant, controls the oscillating movement of this spherical lead safe in which there were channels for nine
source. The main advantage of this system is its repro- source trains. The source trains were made up of cobalt-
ducibility, it being necessary only to select the appropri- 60 pellets and inactive spacers; these were made up to the
ate cam corresponding to the dose distribution required. user's specification at the time of purchase and were
However, the cams have to be specially made for each therefore fixed for the useful life of the sources. The
dose distribution, so it is inflexible in use, as changes in sources and spacers were held in helical steel springs (the
dose distribution cannot be implemented at short source holders), which were welded on to the end of a
notice. Bowden cable, at the distal end of which was an 'eye' con-
Typical source activities are 300 mCi (11.1 GBq) of nector. When in the standby state, the sources rested
cesium-137 for low dose-rate use, but activities up to close to the center of the safe, each in its own channel,
4Ci (148 GBq) of cesium-137 or 20 Ci (740 GBq) of with the end of the Bowden cable projecting from the
iridium-192 were used in high dose-rate versions. rear of the safe.
High dose-rate systems 109

Outside the treatment room was the control and drive


system. This provided three drive cables, each powered
by its own electric motor and independently timed.
These drive cables entered the treatment room (through
a curved track or under the floor, to maintain radiation
protection) and could be connected to up to three (of
the nine) source trains required for use. At the front of
the safe, three hollow transfer tubes were connected to
the output ports of the appropriate source trains, and
these transfer tubes led to the stainless-steel applicators
in the patient. The three drive cables and the three trans-
fer tubes were color coded to enable them to be matched
throughout the system, and mechanical and electrical
interlocks ensured that everything had to be connected Figure 7.3 Joslin-Flynn afterloading applicator (HDR) for the
correctly before a source transfer could be initiated. uterine cervix (courtesy Nucletron BV).
The safe was designed for a maximum content of
50 Ci (1850 GBq) of cobalt-60. Source trains would usu-
about 2 Gy min-1 at the Manchester Point A are obtained,
ally be made up to provide for the various lengths of
and the rectal dose may be kept to less than 60% of the
intrauterine tube and ovoids sizes of the Manchester
Point A dose.
(cervix) System. Some users also used this machine for
the HDR treatment of surface moulds and appropriate
source trains would then be included, for example per- 7.63 Stepping source units
haps a single source pellet for use as the center spot of a
mould. The availability of iridium-192 sources that are physi-
cally small but that contain typically an activity of
10-20 Ci (370-740 GBq) has led to the development of
7.6.2 Selectron-HDR this type of treatment machine, in which a single source
is sequentially stepped through a series of dwell posi-
The Selectron-HDR (Nucletron BV) operates in a similar tions in all the treatment applicators in turn, thereby
general manner to its stable-mate, the Selectron-LDR, in removing the need for several sources or source trains
that source trains consisting of 2.5 mm diameter sources to be present in the machine. There are several machines
and spacers are composed at the time of use, and these are of this type now available; examples are the
then transferred pneumatically to and from the applica- microSelectron-HDR (Nucletron), the Varisource
tors as required. However, there are differences in the (Varian), and various versions of the Gammamed
source type and safe design, to accommodate the HDR (Isotopen-Technik Dr Sauerein). Whilst there are differ-
requirements of this machine. In this case, the sources are ences between the different system relating to source
cobalt-60 (see Chapter 1), each has a nominal activity of design, maximum catheter number and dimensions,
500 mCi (18.5 GBq), and the machine can contain up to number of dwell positions etc., they are sufficiently sim-
20 such sources. There are three output channels, as the ilar to be dealt with generically for the purpose of this
machine can only be used for one patient at a time. The present description.
system is controlled from the operator's desk situated Generally, an encapsulated iridium-192 source is
outside the treatment room. attached to the end of a drive cable. Usually, the machine
The machine is designed specifically for gynecological also contains a 'check cable,' which is essentially a dummy
treatments, and the treatment applicators are similar to source on its own drive cable. The purpose of the check
(in fact, mechanically interchangeable with) those for cable is to be driven out through the transfer tubes and
the Selectron-LDR. However, for a busy center, much of applicators before the source is transferred, in order to
the time advantage of HDR is lost if pre-treatment check the correct connection of all the components and
dosimetry has to be performed between performing the also for obstructions or tight curves. The check cable may
insertion and starting the treatment, and many users also be used as a simulated source for radiography in
therefore use applicator systems whose geometry within some systems. The source and check cable are driven out,
the patient is predictable, allowing the use of pre-calcu- when appropriate, by stepper motors to a claimed posi-
lated treatment plans and standard treatment times. The tional accuracy of 1 mm. Each machine will treat a
Joslin-Flynn applicator (Figure 7.3) is an example of number of channels, for example up to 18 for the
such an applicator system; this allows the operator to microSelectron-HDR and up to 24 for the Gammamed,
select one of two intrauterine tube lengths and one of and each channel may be 'treated' by a number of dwell
two ovoid positions, and it also gives rectal dose sparing positions, for example, up to 48 for the microSelectron-
by means of a rigid retractor. Typically, dose rates of HDR and up to 40 for the Gammamed. The interval
110 Afterloading systems

between the dwell positions depends on the type of 2. BSI 5724 Section 2.17 (equivalent to IEC 602-1-17) (1990)
machine, but is typically 2.5 mm, 5 mm, or 10 mm. Specification for Remote-controlled Automatically-driven
The source diameter is small, typically about 1 mm, so Gamma-rayAfterloading Equipment. London, British
the catheters through which it travels can also be narrow; Standards Institute.
an external diameter of 2 mm (6 French gauge) or less is 3. ICRU Report 38 (1985) Dose and Volume Specification for
common. Also, the length of travel of the source (and Reporting Intracavitary Therapy in Gynecology. Bethesda,
check cable) is long, from 1.5 to 2 m depending on the MD, International Commission on Radiation Units and
machine. The combination of these two features makes Measurements.
this type of machine very adaptable and it may be used 4. N RPB (1988) Guidance Notes for the Protection of Persons
for intraluminal, interstitial, and intracavitary therapy. against Ionising Radiations arising from Medical and
Each of the individual dwell times in each of the Dental Use. Didcot, UK, National Radiological Protection
catheters may in general be different, and this gives the user Board.
the opportunity to optimize dose distributions to suit the 5. Brenner, D.J. and Hall, E.J. (1991) Conditions for the
target volume. Optimization is dealt with more fully in equivalence of continuous to pulsed low dose rate
Chapter 5. With older versions of these machines, data brachytherapy. Int.). Radial Oncol. Biol. Phys.,20,
from the treatment planning computer had to be manually 181-90.
entered into the treatment unit; with multicatheter treat- 6. Fowler, J.F. and Mount, M. (1992) Pulsed brachytherapy:
ments and many dwell positions per catheter, this required the conditions for no significant loss of therapeutic ratio
a lot of data to be entered and was prone to errors. Later compared with traditional low dose rate brachytherapy.
machines used a program card system to transfer the data, Int.J. Radial Oncol. Biol. Phys., 23,661-9.
and the latest machines incorporate combined treatment 7. Mazeron, J.S., Boisserie, G., Gokarn, N. and Baillet, F.
planning and machine control systems into one computer. (1994) Pulsed LDR brachytherapy: current clinical status.
Iridium-192 has a half-life of 74 days, and source In Brachytherapy from Radium to Optimisation.
exchanges are required at (usually) 3-month intervals. Veenendaal,The Netherlands, Nucletron BV.
Frequent source calibrations are therefore required - this 8. Swift, P.S., Fu, K.K., Phillips, T.L, Roberts, LW. and
and other quality assurance aspects are fully dealt with in Weaver, K.A. (1994) Pulsed low dose rate interstitial and
Chapter 9. All the machines have various fail-safe sys- intracavitary therapy. In Brachytherapy from Radium to
tems built into them to reduce the possibility of errors Optimisation. Veenendaal, The Netherlands, Nucletron,
and accidents. BV.
At the time of writing, machines of this type have been 9. Pierquin, B., Wilson, J.F. and Chassagne, D. (1987) Modern
used experimentally for the emerging technique of Brachytherapy. New York, Masson.
intravascular brachytherapy. This is a developing field, so 10. Blasko, J.C., Ragde, H. and Schumacher, D. (1987)
it is inappropriate to go into detail here, but the reader is Transperineal percutaneous iodine-125 implantation for
referred to references 22 and 23 for further information. prostatic carcinoma using trans-rectal ultrasound and
template guidance. Endocuriether. Hypertherm. Oncol., 3,
131-9.
7.7 PULSED DOSE-RATE SYSTEMS 11. Liebel, S.A., Peschel, R.E., Hilaris, B.S., Gutin, P.M. and
Wara, W.M. (1990) Principles of Implantation for Brain
The only commonly available PDR system is the Tumours, Interstitial Collaborative Working Group. New
microSelectron-PDR (Nucletron), which is an adaptation York, Raven Press.
of the microSelectron-HDR machine. Its external appear- 12. Fletcher, G.H., Shalek, R.J. and Cole, A. (1953) Cervical
ance, mode of operation, and safety systems are similar. radium applicators with screening in the direction of
However, there are two major differences. First, the bladder and rectum. Radiology, 60,77.
iridium-192 source contains less radioactivity, typically 13. Suit, H.D., Moore, E.B., Fletcher, G.H. and Worsnop, B.
having an activity of 0.5 Ci (18.5GBq) to 1.0 Ci (1963) Modification of Fletcher ovoid system for
(37 GBq). Consequently, it is also physically smaller, hav- afterloading using standard radium tubes. Radiology, 81,
ing an active length of 0.5 mm and an overall length of 126.
2.7 mm. Second, the operating software is different, 14. Marbach, J.R., Stafford, P.M., Delclos, L and Almond, PR.
allowing the source movement to be programmed for the (1985) A dosimetric comparison of the manually loaded
pulsed nature of the treatment, as described in section 7.3. and Selectron remotely loaded Fletcher-Suit-Delclos
utero-vaginal applicators. In Brachytherapy 1984.
Veenendaal, The Netherlands, Nucletron BV.
REFERENCES 15. Jackson, A.W. and Davies, M.L (1983) In Radiation
Treatment Planning, ed. N. Bleehan, E. Glatsein and J.
1. AAPM (1993) Remote Afterload ing Technology, AAPM Haybittle, New York, Marcel Dekker.
Report No. 41. New York, American Institute of Physics, 16. Wilkinson, J.M., Moore, C.J., Notley, H.M. and Hunter, R.D.
for The American Association of Physicists in Medicine. (1983) The use of Selectron afterloading equipment to
References 111

simulate and extend the Manchester System for and Williamson J.F. (1998) High dose-rate brachytherapy
intracavitary therapy of the cervix uteri. Br.J. Radial., 56, treatment delivery: report of the AAPM Radiation
404-14. Therapy Committee Task Group No. 59. Med. Phys., 25(4),
17. Rowland, C.G. (1985) Treatment of carcinoma of the 375-403.
oesophagus with a new Selectron applicator. In 21. O'Connell, D., Joslin, C.A., Howard, N., Ramsay, N.W. and
Brachytherapy 1984. Veenendaal, The Netherlands, Liversage, W.E. (1967) The treatment of uterine carcinoma
Nucletron BV. using the Cathetron. fir. J. Radiol., 40,882-9.
18. Flores, A.D. (1989) Remote afterloading intracavitary 22. Schopohl, B., Liermann, D., Pohlit, LJ. etal. (1996) 192lr
irradiation for cancer of the nasopharynx. In endovascular brachytherapy for avoidance of intimal
Brachytherapy 2, Veenendaal, The Netherlands, hyperplasia after percutaneous translumenal angioplasty
Nucletron BV. and stent implantation in peripheral vessels: 6 years of
19. de Ru, V.J., Hofman, P., Struikmans, H., Moerland, MA experience. Int.]. Radial Oncol. Biol. Phys, 36,835-40.
Nuyten-van-Deursen, M.J.H.and BattermannJ.J. (1994) 23. Nath, R.,Amols, H.,Coffey, C.etal. (1999) Intravascular
Skin dose due to breast implantation for early breast brachytherapy physics: report of the AAPM Radiation
cancer. In Brachytherapy from Radium to Optimisation. Therapy Committee Task Group No. 60. Med. Phys., 26(2),
Veenendaal, The Netherlands, Nucletron BV. 119-52.
20. Kubo, H.D., Glasgow, G.P., Pethel, T.D., Thomadsen, B.R.
8
Quality assurance in low dose-rate afterloading

ERICD.SLESSINGER

8.1 INTRODUCTION devices manufactured by the Nucletron Corporation BV,


specifically the Selectron-LDR and the microSelectron-
LDR. The principles of quality assurance that have been
The advent of remote afterloading brachytherapy applied for those devices serve as a basis for comparable
devices has required that the scope of quality assurance systems.
in brachytherapy be broadened substantially. This is due
to the fact that these devices are designed to perform the
basic tasks that previously had been directly controlled
8.2 PREPARATION FOR A LOW DOSE-RATE
by staff: source selection, transport and positioning in
REMOTE AFTERLOADING PROGRAM
the treatment applicators, the monitoring of elapsed
treatment time, and treatment termination. These
remote functions should practically eliminate the radia- 8.2.1 Equipment selection
tion exposure to anyone involved in the treatment and
care of brachytherapy patients. A comprehensive quality The selection of appropriate equipment is one of the first
assurance program is necessary to verify that these steps toward the establishment of a remote afterloading
devices perform in accordance with the manufacturers' program. The type of brachytherapy procedures to be
specifications to deliver treatment accurately and safely performed (intracavitary, interstitial, intraluminal etc.)
[1]. with remote afterloading should be determined and then
This chapter describes the methodology for achieving matched to the most suitable device. These devices offer
those ends. The process starts with planning for the a variety of features for consideration, including source
equipment and the treatment facility, the application for types and activities, applicator systems, the number of
authorization to use the equipment, the coordination of treatment channels, the means for programming treat-
the facility construction and the equipment installation. ment times, and the ability to customize source configu-
The facility and equipment must be thoroughly tested, rations. Other basic device design features include the
new treatment procedures must be established, and per- mechanism for source transport, the monitoring of cor-
sonnel trained and an ongoing quality assurance and rect source positioning, the safety interlocks and fail-safe
equipment maintenance program must be developed. A systems, and the shielded source storage containers. For
successful quality assurance program requires a team a more complete description of remote afterloading sys-
approach, incorporating the radiation oncologist, med- tems, see Chapter 7.
ical physicist, device manufacturer, brachytherapy tech- The review, selection, and specification of applicator
nologist, nurse, dosimetrist, health physicist, and service designs must be done carefully, consistent with the antic-
technician. The experience of this author in low dose- ipated treatments. This process will directly influence the
rate (LDR) remote afterloading has been exclusively with selection of the source activities and possibly the
Preparation for a lose dose-rate remote afterloading program 113

selection of the treatment machine as well. If a radiation utility. Several papers [2-5] have reported on source
oncology department is converting from manual after- inventory specification, source assembly design, and
loading to remote afterloading, maintaining similar source-spacer configurations.
applicator styles and source activities is important. For For interstitial work, the user can select rigid metal
example, if the Fletcher-Suit afterloading tandem and needles or flexible plastic needles or catheters. The
ovoid system had been used, then a comparable applica- availability of templates from the manufacturer should
tor set, compatible with the remote afterloading device, be explored, as well as the compatibility of existing
should be requested. In addition, applicators for treating templates with the remote afterloading device. For
the vagina, endometrium, oesophagus, bronchus, and interstitial applications, a permanent inventory of fixed
nasopharynx should also be considered. cesium seed source trains or an inventory of temporary
With a remote afterloader like the Selectron-LDR, lin- iridium wires or seed ribbons, or a combination of
ear sources are replaced by uniform activity spherical both, may be used. The purchase of cesium seed source
sources configured with inactive spherical spacers. These trains is practical if one can anticipate an appropriate
spherical cesium-137 sources have an outer diameter of source inventory. The cesium seed source trains are
2.5 mm and are available with a maximum activity of 40 expensive, but can be used over a long time period,
mCi (1480 MBq or 115 U) per source. When specifying whereas the iridium, though requiring frequent pur-
the source inventory for this type of remote afterloader, chases, allows the user more options. A rationale for
the following questions should be addressed: choosing a specific cesium seed ribbon inventory has
been reported [6]. Whether cesium or iridium is used
What is the range of prescription dose rates for the
for interstitial application, the positioning of the active
different clinical applications that are anticipated?
length within the needle or catheter must be well
How many channels may be in use at one time?
understood, because these techniques can use varied
How will the active and inactive source pellets be
active and inactive source lengths as well as varied nee-
configured to achieve suitable dose distributions?
dle or catheter lengths. Special procedures must be
What is the recommended maximum activity for the
established for iridium source preparation and for veri-
main and intermediate source safes?
fication of accurate interstitial source placement. These
These questions should aid in deciding the total number procedures are reviewed in greater detail later in this
of sources and the activity of each source. Combinations chapter.
of eight sources and spacers can be used to compose 2-cm
long sequences that can replace 2-cm linear sources. The
medical physicist should determine the ideal source 8.2.2 Site preparation
strengths to deliver the prescribed dose rates for each clin-
ical application as specified by the radiation oncologist, LOCATION
and a treatment planning computer should be used to
Careful planning for a remote afterloading facility is
verify the design of the source-spacer configurations. At
very important to achieve convenience and safety for
the Mallinckrodt Institute of Radiology, St Louis,
the patient and staff, and to avoid unnecessary costs.
Missouri, a six-channel device with a 36-source inventory
Physicians, physicists, nursing personnel, and the manu-
(36 U/source) has proven to be adequate for enabling two
facturer should all be involved in the planning.
simultaneous intracavitary treatments. Further discus-
Typically, LDR brachytherapy is given in a private
sion of spherical source configurations is presented in the
patient room on a surgical or cancer nursing division. It
clinical implementation section of this chapter.
is ideal if the brachytherapy room is near to the nurse
The specification of sources for a remote afterloader
station and to the brachytherapy preparation labora-
that uses drive motors to transport source-cable assem-
tory, while being as far as possible from unrestricted
blies requires a different rationale, because the source
patient rooms. Multiple LDR treatment rooms should
trains usually cannot be easily reconfigured, if at all. A
be adjacent to each other. Figure 8.1 shows an example
list of required source trains, their activities, and active
of a floor plan of an extensive LDR remote afterloading
lengths must be established that will satisfy most clinical
facility.
situations. Certain applicators, such as the intrauterine
tandem, may require source trains composed with dif-
SHIELDING CONSIDERATIONS
ferential linear activity. Their designs can be based on the
non-uniform linear activities that had been used for The shielding design must be based on the anticipated
the manually afterloaded treatments. The position of the maximum source activity loadings and duration to
source in the applicator can also be specified by the user, limit exposure rates and total exposure in unrestricted
but the physical constraints of source rigidity and the areas to less than the maximum level allowed by the
curvature of the source transport channels may not nec- user's regulatory agency. In the USA, for example, the
essarily allow ideal source alignment. In that case, dosi- United States Nuclear Regulatory Commission
metric analysis should be used to evaluate the clinical (USNRC) limits the radiation exposure to 2 mrem
114 Quality assurance in low dose-rate afterloading

Figure 8.1 Floor plan for a four-treatment device remote afterloading facility at Barnes-Jewish Hospital in St Louis, Missouri. The
equipment shown consists of two microSelectron-LDRsfor intracavitary applications, a six-channel Selectron-LDR for simultaneous
treatments in two adjacent rooms, and a microSelectron-LDRfor interstitial Indium located in the room opposite to the source
preparation laboratory where the two air compressors for the systems are housed.

(0.02 mSv) in an hour to any non-monitored person, more information on this subject, the reader should
with an annual limit of 100 mrem (1 mSv) [7]. The refer to Chapter 10.
USNRC ALARA (as low as reasonably achievable) pro-
gram limits exposure in restricted areas to 500 mrem (5
FACILITY DESIGN
mSv) per year. For LDR brachytherapy rooms that were
previously used for manual afterloading, it is possible to Room design details for remote afterloading brachyther-
use rolling bedside shields to protect unrestricted areas apy are summarized in Table 8.1. Electrical power to the
on the same floor, but lead thicknesses in the range of device should be provided from a dedicated circuit that
0.6-1.3 cm should be anticipated for the floors above is also served by emergency power. If compressed air is
and below. New construction is best served with required, then the decision whether to use in-house or
shielded walls. The recommendations for room shield- free-standing compressors must be made. Although it
ing should be made after studying appropriate blue- may seem simpler to use the hospital air, a dedicated
prints and considering the actual location of the compressor specifically suited to the device can give
brachytherapy patient within the room, as well as the greater assurance as long as it can be situated far enough
weight limitations of the room [8]. Empirical radiation from the patient so that its noise is not disturbing. It is
survey testing of existing room shielding may also be possible to install an air compressor in a small hallway
performed to determine if shielding deficiencies are enclosure or in the source preparation laboratory, pro-
present before installing remote afterloading equipment vided there is adequate space for inspection and servic-
[9]. The National Council on Radiation Protection and ing.
Measurements (NCRP) Report 49 [10] should be used An area radiation monitor with an independent
to guide the determination of the shielding specifica- secure power supply should be installed adjacent to the
tions that will achieve the required exposure limits. For implant patient's bed for maximum sensitivity. A remote
Preparation for a low dose-rate remote afterloading program 115

Table 8.1 Treatment room details for low dose-rate remote tical, so that one patient can be safely visited without dis-
afterloading brachytherapy turbing the treatment in the adjacent room. Door locks
Area radiation monitor (with a dedicated check source and
should be installed to secure the treatment room when
battery pack) and remote display not occupied by a patient, because the remote afterload-
ing device and its source inventory generally remain in
Closed circuit TV (monitor at nurses' station)
the room. 'Radioactive Material' and 'Radiation Area'
Compressed air system
warning signs must be posted on the room door or at the
Electric power on emergency power circuit entrance to the brachytherapy ward. These warnings can
Emergency container and equipment conveniently be embossed on a hanging door placard
Remote controls with treatment status displays in the hallway designed also to display treatment forms, nurse instruc-
and at the nurses' station tions, and the room diagram.
Treatment tubing support device
AUTHORIZATION FOR REMOTE AFTERLOADING
Door-mounted board for posted warnings and instructions
Door interlock system In some countries, it is necessary to apply for authoriza-
Door lock tion to use an afterloader. Registration of the afterloader
Intercom to hallway and nurses'station
may also be necessary depending upon the policies of the
agency that regulates its use. The regulatory agency
Rolling bedside shields
should specify what information must be submitted
Permanent shielding in floor and above before authorization and/or registration can be consid-
Wall pass-through for two simultaneous treatments from one ered. If the agency is not very familiar with afterloading
device technology, the device manufacturer should be able to
suggest which information is required to submit,
because the manufacturer will have also gone through a
similar submission of specifications and information in
display for the area monitor is necessary, situated either
order to obtain the approval to market the device. Table
outside or just inside the doorway to alert anyone enter-
8.2 lists the points that should be addressed when sub-
ing the room about exposed sources before approaching
mitting a license amendment proposal to the USNRC.
the implant patient. The area monitor is intended to
Generally, one should not commit in the application to
indicate the safe status of the sources in the entered
any procedures that are not required by the licensing
room only. Therefore, it may be necessary to mount the
agency [8]. However, the licensing agency will be seeking
area monitor against a small lead shield on the wall so
assurance that the proposed treatment program will be
that it is not sensitive to radiation from an adjoining
safe and has been well thought out.
brachytherapy room.
The remote controls for the afterloaders are usually
INSTALLATION
installed in the corridor, adjacent to the patient's room
door. Typically, the treatment room door is closed dur- The installation of remote afterloaders should be coordi-
ing treatment and a door interlock switch is installed to nated by a physicist or biomedical engineer. The installa-
automatically retract all sources into the intermediate tion process will proceed smoothly as long as the needs
safe in the event that the treatment interrupt button is of the manufacturer's installation engineer, in-house
not activated prior to entering the room. A window in engineering, clinicians, nurses, and physicists are under-
the door can provide only limited visual contact with the stood. The process should begin with a pre-installation
patient. It is recommended to install a closed circuit tele- meeting, at which time the responsibilities of the manu-
vision camera for remote patient observation from the facturer and the hospital are defined and agreed upon. If
nurse station. In addition to the normal intercom system existing shielded brachytherapy rooms are to be con-
from the nurse station to the patient, a two-way hallway verted for remote afterloading, temporary relocation of
intercom to the patient is also practical for limiting the brachytherapy patients may be required during the
number of treatment interruptions. A remote treatment installation process. Appropriate shielding similar to that
status display at the nurse station is also recommended, in regular use should be provided for these temporary
which can indicate whether treatment is progressing, is areas. If no supplemental temporary shielding is used,
interrupted, or if an alarm status exists. Display of the vacating adjacent areas will be necessary unless the expo-
remaining treatment time should also be available. If one sure rates are within the allowable limits. Therefore,
remote afterloading device is capable of treating two radiation surveys are necessary to verify acceptable expo-
patients simultaneously in adjacent rooms, then a wall sure levels in the unrestricted areas around the tempo-
pass-through is needed for the source transport tubing. rary brachytherapy rooms.
The wall opening should be devoid of sharp edges that The manufacturer's engineer initially should review
could damage the tubing. Each treatment room should and verify receipt of all equipment. The project coordi-
have its own independent controls installed, when prac- nator should oversee this process, maintain a file of all
116 Quality assurance in low dose-rate afterloading

Table 8.2 Information to submit to the licensing agency when dures and results should be carefully reviewed by the
requesting authorization for remote afterloading responsible physicist to determine which tests should be
Remote afterloader model and manufacturer
repeated and which additional tests need to be added to
the acceptance testing procedure.
Source description (radionuclide, size, the activity,
manufacturer, and physical construction)
Certification of federal registration of the device
83 ACCEPTANCE TESTING
The intended clinical applications
The intended users, their training, certification, and
experience
8.3.1 Introduction
Radiation-detection instruments to be used
Acceptance testing for a new remote afterloading device
Facility floor plan and elevation must be performed prior to clinical implementation in
Calculations that demonstrate acceptable exposure levels in order to certify that the device performs in accordance
unrestricted areas with the manufacturer's specifications. If the treatment
Describe area security, including access to operating keys, door facility is also new, then it must also be carefully evalu-
interlocks, and radiation warning systems ated. This initial testing also establishes a starting point
Describe patient viewing and communication for machine performance evaluation and provides the
Describe dosimetry equipment, calibration procedures and basis for the development of an ongoing quality assur-
frequency, leak test procedures and frequency, and the ance program. There have been several acceptance test
qualifications of those performing the tests approaches reported in the literature [8,11-16]. AAPM
Emergency procedures and frequency of mock emergency Report 41 divides the acceptance testing process into sev-
drills eral broad categories, including evaluations of the
Personnel-monitoring program radioactive sources, the mechanical and electrical opera-
tion of the remote afterloading device, the radiation
Describe the titles and locations of procedure manuals
monitors and facility, the applicators, and the treatment
Procedures to prevent multiple treatment devices from
planning computer. The following sections of this chap-
operating simultaneously
ter address many of the issues that comprise a thorough
Quality assurance program acceptance-testing program.
Training of the source exchangers The testing sequence begins with new source evalua-
Training and frequency for operators tions. Once the sources are loaded into the machine,
Disposal of decayed sources radiation surveys are performed. This is followed by the
evaluation of the safety features and interlocks, machine
Adapted from AAPM eport No. 41 [8].
performance and applicator function, and finally the
treatment planning system. Some of these tests will yield
quantitative results, however much of the testing
equipment receipts, and verify that the complete order
involves verification of correct function.
has been received. The engineer should test the equip-
ment prior to installation, verifying such items as correct
battery function, electrical parameters, air pressure sen- 83.2 Brachytherapy source testing
sors, and switches. The installation process includes
cable routing between the machine and the remote con- Several excellent reviews of brachytherapy source testing
trols outside the treatment room, wiring the door inter- can be found in the literature [8,12,17]. The process
lock mechanism, and installation of the radiation begins with a careful review of the new source certifi-
monitors. Additional cables are routed to the nurses' sta- cates. The isotope, its activity or air kerma strength, the
tion to connect to the remote treatment status display uncertainty of the calibration, the active and physical
and the closed circuit television monitor. If remotely lengths, and source encapsulation must all be verified to
located air compressors are to be used, a pipefitter will assure that the correct sources have been received. The
install the appropriate lines to a compressed air outlet documentation of acceptable leak tests (<5nCi or 200
near to the treatment machine. The manufacturer's engi- Bq removable activity) within the previous 6 months
neer should verify that all cables are properly connected should also be checked. The sources should be visually
and functioning correctly. If several rooms require examined through shielded glass, looking for any signs
installation, it may be possible to schedule the work from of damage. Any engraved serial numbers or other identi-
one room to the next, with the manufacturer's engineer fying details should be recorded. If there is any sugges-
testing and verifying the installation as it proceeds. This tion of damage to any sources or if the sources have not
will also allow the physicist to begin the evaluation of the been leak tested within the previous 6 months, new leak
installation, possibly prior to the completion of all the tests must be performed. After the sources have been
rooms. The device manufacturer's equipment test proce- loaded into the remote afterloader, periodic leak testing
Acceptance testing 117

can be accomplished by wiping the inner surfaces of the 833 Radiation surveys
source transport tubes or, if accessible, the inner surface
of the storage container positions. The manufacturer Once the documentation and testing of the new
should provide detailed source diagrams indicating the brachytherapy sources have been satisfactorily com-
source construction, dimensions, and materials used. pleted, the source inventory is loaded into the main safe
These source documents are very important and should of the remote after-loading device. Radiation surveys are
be copied and filed so that working copies are available then performed to monitor the exposure rate on the sur-
for fast reference and the original documents are safely face and at 1 m away from the main and intermediate
stored with other source certificates. A bound logbook source safes. By wrapping the surface area around the
should be obtained for each remote afterloader for safes with a sensitive film wrapped in light, tight paper,
recording tests and measured results, and for documen- shielding defects can be detected and the areas where the
tation of the routine quality assurance testing. The initial surface exposure is relatively high can be located.
entries into this logbook should pertain to source docu- Average and maximum exposure rates at the surface and
mentation, listing the source model numbers and serial at 1 m should be documented and should be consistent
numbers, activities, active and physical lengths, encapsu- with the manufacturer's specifications and national
lation material and thickness. Copies of the source cer- guidance. Radiation protection aspects are dealt with in
tificates and diagrams should contain all of this more detail in Chapter 10.
information. The assigned storage container position for
each source should also be recorded when relevant.
The new sources should be autoradiographed to eval- 83.4 Safety features
uate the uniformity of the activity distribution and its
location within the physical length. The results are then The safety features of the remote afterloading device and
compared to the source diagrams. The autoradiographs the facility must be thoroughly evaluated. Table 8.3 lists
are obtained by placing the sources in uniform close
contact with film that is wrapped in light-tight paper. Table 8.3 Safety features of a remote afterloading treatment
The source position must be maintained for a brief time program that should be tested or established and available
period, usually 30 s or less, depending on the film sensi-
tivity and source strength. Kodak Ready-Pack localiza- Source leak testing
tion film is suitable for this purpose. Catheters or other Radiation exposure rate surveys in compliance with the
narrow source applicators can be used to maintain pre- regulations
cise source positioning. Reference marks such as pin- Radiation warning lights inside and outside the treatment
pricks are used to indicate the source location on the room function properly
developed film, and the area of relatively high optical Independent radiation monitor in the room and its remote
density can be evaluated in relation to those marks. Jones display function properly using a check source with normal
[12] has described an autoradiograph technique that and with back-up battery power and during treatment
uses moulded wax to position and support the sources or Closed circuit TV system and intercom systems
applicators, with lead foil markers embedded between Door interlock causes source retraction and cannot resume
the wax and the film to provide a radiographic image of treatment until the on/off switch is activated and sources
identification marks and scales for precise comparisons. cannot be driven out of the safe with the door open
These films can be evaluated by visual inspection, using Treatment controls
a ruler to compare the stated active length against the Treatment status indicators, outside of treatment room and at
film image and the activity location relative to the phys- the nurses'station
ical ends of the source. When possible, radiographs of
Back-up storage batteries used during power failure
the sources provide additional verification of source
Disconnected applicator interlock
construction details and, when combined with the
autoradiograph exposure, the image of the physical Compressed air lines maintain adequate pressure under load
structure superimposed over the autoradiograph image and for treatment duration
provides the most complete evaluation. The use of a Back-up compressed air reservoir for source retraction when
scanning optical densitometer could provide additional normal air compression fails
graphic information to identify accurately the center of Emergency-off switches and equipment for source removal,
the source activity and to evaluate the activity unifor- handling, and storage
mity. Typically, the results of the source evaluations Treatment bed and bedside shields arranged to optimize
should appear practically identical for all sources of the protection
same model. If any variants are discovered, those sources Hand-held radiation exposure survey meter
should be isolated and the source manufacturer con- Radiation warning signs and posted instructions
tacted. The subject of brachytherapy source calibration
Room and afterloader secured when not in use
is covered in Chapter 3.
118 Quality assurance in low dose-rate afterloading

the safety features to be tested, equipment that should be


available, and procedures to be established. These
include the treatment controls, safety interlocks, and the
response to an electrical power disruption or an air com-
pression failure. The area radiation monitor should be
evaluated with its normal power supply and with its
back-up battery power. The sensitivity of the radiation
monitor to a minimal source loading should be verified
as well as its insensitivity to radiation from an adjacent
room. The operation of the closed circuit television cam-
era, monitor system, and intercom system should also be
checked.

83.5 Source transport and applicator tests

Applicator tests are performed to verify functionality


and to document source position within the applicator.
Applicators should be easily coupled to and decoupled
from the source transport tubing and should be Figure 8.2 Radiographic evaluation of the source position in
designed to detect when an applicator is not adequately the microSelectron-LDR shielded ovoid. The dummy source
connected. The integrity of the source guide tubes shown here is constructed to appear identical to the actual
should also be evaluated. Cable-driven source assem- source. An autoradiograph (not shown) demonstrated agreement
blies should have source guide tubes of constant length between the applicator positioning of the dummy and actual
to assure 1 mm source position accuracy. For pneumatic sources. Solder wire is used to delineate the surface of the
source transport, the transport tubing should be plastic caps that enlarge the surface diameter to 2.5 and 3.0 cm.
inspected for leaks, constrictions, and other obstacles. If These plastic caps do not extend the anterior ovoid surface.
specific transport tubes are designed to connect only to
specific applicators, this should be tested, as well as all
possible combinations of applicators and transport
tubes to detect faulty connectors. The applicators
should be visually inspected to evaluate the mechanical ing. Alternatively, direct measurement of the transit radi-
integrity and radiographed with dummy sources in ation dose can be made using thermoluminescent
place to clearly document source position with respect dosimetry. These measurements should be repeated at
to the applicator surfaces and to verify agreement with least annually. The many treatment interruptions that
the applicator design. For certain applicators, more than can occur during LDR remote afterloading treatments
one radiograph may be necessary to view the source should be considered in order to determine the total
position along different applicator axes. The location dose that normal tissues may receive. However, the mag-
and size of internal applicator shields should also be nitude of this transit dose should not be significant. To
documented. To illustrate a potential problem, Figure illustrate this point, assume that transported sources
8.2 shows the dummy source position within the come into close proximity to a normal tissue point for
microSelectron-LDR shielded ovoid. Due to the rigidity effectively 1 s in each transport direction. For a 40-h
of the source, it assumes the tipped alignment relative to treatment, the number of interruptions (2 s of close
the ovoid axis. This was not considered to compromise exposure per interruption) to give 1% of the total treat-
its clinical utility in this case. Autoradiographs with ment dose to normal tissue would have to be close to 720
sources loaded in the applicators demonstrate the relia- and, depending on how close this point is to the implant
bility of the radiographic markers to indicate actual site, this transit dose may be relatively low when com-
source positions. Dosimetry measurements should also pared to the dose received from the sources while in the
be made to evaluate the effects and adequacy of the treatment position.
shields and to determine if any transmission corrections If transparent applicators are available, the position of
are indicated. simulated dummy sources and radioactive sources can
The speed of source transport can be determined be observed via closed circuit television within an accu-
indirectly by methods based on ionization measure- racy of 1 mm. Certain disposable applicators, such as the
ments or can be observed using video equipment. These Norman-Simon capsules, and flexible interstitial needles
techniques have been described by Meigooni et al. [18]. require quality assurance testing to verify consistent
The resultant velocity can be used to predict the transit insertion depth. The Norman-Simon capsules should be
dose to tissues that are close to the source transport tub- tested to verify source insertion capability and autoradi-
Acceptance testing 119

ographs obtained to demonstrate the actual source loca- sensors in those systems are used to detect whether or
tion relative to the capsule tip. For interstitial applica- not a source loading has been completely transported
tions, the appropriate gauge needle or catheter must be into the treatment applicator. A control pellet at the dis-
established. A 20-cm long, 15-gauge, plastic flexiguide tal end of the source assembly or source train should seal
needle has been used for perineal applications using the the inner tube of the source container, preventing airflow
microSelectron-LDR. All new flexiguide needles should into the source tube when the sources are completely
be checked for length accuracy and trimmed if necessary. extended into treatment. If this does not occur within a
A special needle obturator can be marked to indicate the certain time period, the sources should be automatically
20-cm insertion depth and serve as a guide if trimming withdrawn into the intermediate safe, eliciting an alarm
is necessary. If new plastic materials are being used, the condition.
effects of gas sterilization should be investigated. Autoradiographs are very important for verification of
Shrinkage of the plastic during sterilization can compro- correct source selection, source configuration, and
mise the source transport and reduce the insertion source positioning. The applicator must be secured as
depth. close as possible to the film. This technique is similar to
the one described earlier for initial source testing, but
now the intent is to determine exactly where the sources
83*6 Functional tests are positioned within the treatment applicators during
treatment, and this should be verified on a regular basis.
Functional tests to be performed are listed in Table 8.4.
The International Standard recommended by the
Additionally, a list of suitable tests can be found in refer-
International Electronical Commission (IEC) specifies a
ence 19. For afterloader systems that utilize air compres-
maximum variation in source position within an appli-
sion for source transport, simulated treatments should
cator set to be 2 mm [20]. Williamson [17] has sug-
be performed to evaluate the reliability of the air com-
gested that geometric accuracy of 1 mm should be
pression supply under full demand and the minimum air
achievable. Radiographs with dummy sources loaded
compression that the compressors will allow. Airflow
should clearly delineate source position in all applica-
tors. Comparisons between simulator radiographs with
dummy sources in place and autoradiographs with
applicator surfaces delineated provide the basis for
Table 8.4 Operations that should be verified by functional establishing source position. However, the distance
testing of a remote afterloading device between the sources and the film can limit the measure-
Console functions: key switches, main power, battery power,
ment precision of source position reproducibility,
source on/off, door open/close because as the applicator diameter increases, the distance
to the film also increases, causing the image of the source
Programmability of treatment
activity to be less discrete. Autoradiographs for each
Correct console displays and treatment data printout
applicator should be marked so that localization of
Printer function source position can be correlated to the dummy source
Timer accuracy and transit time measurements radiograph. If the remote afterloader and a radiographic
Sources retract to safe at the end of a preset time, when unit can be used together, combining the radiograph and
treatment is interrupted, when electrical power or air autoradiograph onto one image makes the evaluation of
compression is lost, when the room door is opened, or when actual source position within the applicator direct, sim-
the emergency off button is activated ple and precise. The comparison of this film to the radi-
Treatment cannot proceed if applicators are not connected ograph of the dummy source marker position within
correctly or are obstructed that applicator also provides very precise positioning
Source selection or configuration (autoradiograph) verification. The position of radiographic markers
Source transport and positioning (autoradiograph) should vary by less than +1 mm.
Prior to commencing a treatment, an autoradiograph
Air compressors maintain adequate compressed air
should be obtained to verify correct source selection and
Response to loss of air compression
the channel and applicator that will contain each source.
Maintenance of remaining treatment time when treatment is This autoradiograph is especially critical for interstitial
interrupted or after a power failure iridium seed ribbon assemblies, where the correct source
Battery voltage under load is adequate and operating design for each channel must be verified. The most direct
functions are retained under battery power autoradiograph process involves sources transported
Return of sources to intermediate safe and main safe into the same treatment applicators as those in the
Accuracy of source decay computations patient. If a more general autoradiograph device is used,
Proper operation of radiation detectors in the afterloader the relation between source extension in an applicator
and its position in the autoradiograph device must be
Manual means for source retraction if the remote system fails
established. This involves the use of dummy sources that
120 Quality assurance in low dose-rate afterloading

can either be visualized and measured directly when 83*7 Acceptance test report
inserted or radiographed to determine where the sources
extend relative to reference fiducial marks. For the inter- The results of all tests performed during the commis-
stitial sources, this enables not only verification of the sioning of a remote afterloading device and facility
number of seeds per channel but also documentation of should be summarized in a report, which should serve as
the inactive length. a benchmark from which the quality assurance program
Tests should be performed to verify that interlocks can continue. In addition to the test results, the report
operate effectively. These tests should include attempting should document operational procedures and describe
to treat without an applicator properly connected. If an the basic mechanics of the system. If the report is for a
applicator is designed to be connected only to a particu- new remote afterloading facility, treatment-related pro-
lar channel, that specificity should be tested. A dummy cedures and a quality assurance program should also be
source used with a device such as the microSelectron- specified in the report prior to clinical implementation.
LDR can be intentionally unsnapped from the drive Some of these clinical procedures are discussed in the
cable to test that the absence of the source will be following sections. Table 8.5 gives an example of the con-
detected upon source retraction. The door interlock tents of an acceptance test report.
must also be tested, by verifying that treatment is pre-
vented unless the door is completely closed, and by veri-
fying that treatment is interrupted should the door be
opened.
The treatment timing mechanisms must be tested Table 8.5 Example table of contents for a remote afterloading
for accuracy, and source transit time should be deter- device acceptance report
mined. These tests can be performed using a thimble
1. Institution and location
ionization chamber that is positioned in close proxim-
ity to sources in an applicator. Once the sources are 2. Facility name
transported into treatment, an integrated charge can be 3. Remote afterloading device
measured over a certain time period to determine the 4. Sources and applicators
static ionization current (coulombs/s). Additional mea- 5. Tests and results Source calibration
surements of charge for different programmed treat- Radiation safety
ment times are then used to determine the actual Mechanical
'measured' time by dividing the measured charge for Programming a treatment
the programmed treatment time by the static ioniza- 6. Procedures Machine start-up and daily
tion current [17]. A curve-fitting routine is then used quality assurance
to relate the time measured to the time set by the lin- procedures
ear relation: Nurse's instructions
Radiographic localization
Timemeas = (Timeset)(Timer accuracy slope) + Transit time Computed clinical dosimetry
Emergency procedures
Treatment completion
In general, the measured time should agree with the
procedures
machine-set time within 2%, but, as treatment time Patient instruction
decreases or the number of interruptions increases, the Room assignment
dose effects due to transit time error increase. Quality assurance program
Williamson has reported timer error to be of the order of Physician loading and
a few seconds, while absolute timer accuracy is usually unloading procedures
within 1%. The distance between the dosimeter and the 7. Summary and
sources should be kept constant and as small as possible, recommendations
because this parameter will affect the timer error deter- 8. Appendix Source data
mination. Radiation surveys
Another way to determine transit time is similar to the Applicator radiographs
method used for cobalt teletherapy units [21], where Source position
integrated charge is measured for one exposure period autoradiographs
and then compared to the same total exposure time Tim ing tests
administered over several on/off sequences. For both Special forms and techniques
methods described, the results will be clinically applica- License application
ble if the distances between the source and chamber are Manufacturer's field service
reports
similar to a typical treatment depth. Additional func-
Machine specification
tional tests are included in Table 8.4, many of which can
Error codes
be verified simply by observation.
Quality assurance procedures and clinical implementation 121

8.4 QUALITY ASSURANCE PROCEDURES line source of active length n x S, i.e., (6) x (2.5 mm) =
AND CLINICAL IMPLEMENTATION 15 mm.
Others have also reported on source-spacer pellet
configuration schemes for the replacement of an intra-
8.4.1 Conversion from manually loaded cavitary Manchester radium source technique [4] and
tube sources to source-spacer pellet for source optimization in vaginal cylinder applica-
configurations tions using a simulated annealing algorithm [5]. The
limitations of point source algorithms to model
A methodology for converting manually loaded, 2-cm Selectron source configurations have also been
long sources to source-spacer configurations has been reported, and measured dose distributions have
described by Grigsby et al [3]. This approach replaces demonstrated where the effects of attenuation by inac-
the 2-cm long sources by groups of eight 2.5-mm tive spacers, other sources, and applicators are the
source-spacer pellets. To duplicate the inactive ends of greatest [23,24]. This is discussed further in the dose
the tube source, the first and eighth positions are computation section.
reserved for spacer pellets. The remaining six positions
contain the active sources, distributing them as uni-
formly as possible. Isodose comparisons of linear
sources and active/inactive pellet configurations gener- 8.4.2 Conversion from manually loaded
ated by the treatment planning system should be used to tube sources to motor-driven source-cable
match the two dose distributions. The Fletcher-Suit assemblies
ovoids designed for the Selectron have six active source
positions between the bladder and rectal shields. The The specification of source activities and active lengths
active sources are therefore arranged within those posi- for motor-driven remote afterloaders is a relatively
tions. Table 8.6 lists some of these source configura- straightforward process. Because the sources cannot be
tions. The concept of using six source positions to reconfigured, one must list all the sources anticipated to
specify an active length close to 14 mm is also supported be needed. An example of an intracavitary cesium source
by the analytic approach reported by Williamson [22], inventory for a 15-channel, cable-driven, remote after-
which states that a linear array of n point sources, loader is shown in Table 8.7. Each source should have a
spaced at center-to-center intervals S, approximates a documented assigned location in the main storage con-
tainer so that prescribed sources can be easily identified.
The design of a remote afterloader will sometimes
Table 8.6 Cesium source and spacer arrays developed by limit how closely one can replicate manually loaded
Grigsby et al. [3] to replace the previously used 2-cm tube sources brachytherapy technique. For example, if the path of the
source transport tube through an applicator such as a
Fletcher-Suit-style ovoid will not permit the use of a
2-cm long rigid source, then a shorter source length may
144 U -2 - 4 5 - 7 - 72 U - 2- - 5- be necessary. This was the case when an 8.5-mm active
72 U -2 7 _ 144 U 1 - 3 4 - 6 length source replaced a 14-mm active length cesium
180 U 1 2 3 - 5 6 tube source and, as a consequence, the dose rate on the
216 U 1 2 3 4 5 6 lateral surface of the ovoid increased by 6% to 15% as the
Each 2.5 mm source pellet is nominally 36 U (5 mg radium ovoid diameter decreased from a 3 cm to the 1.6 cm mini
equivalent). ovoid [2].

Table 8.7 The intracavitary cesium source inventory for a microSelectron-LDR1

Norman-Simon Capsule 12 8.5 9.11 1-12 1-12


Mini ovoid 2 8.5 9.74 19,20 13,14
Shielded ovoid 2 8.5 18.93 21,22 13,14
Shielded ovoid 2 8.5 28.50 23,24 13,14
Tandem 1 40.0 19.12-9.54 38 15
Tandem 1 60.0 9.54-19.12-9.54 39 15
Tandem 1 60.0 19.12-9.54-9.54 40 15

a
Purchased by the Mallinckrodt Institute of Radiology for treatments given at Barnes-Jewish Hospital, St Louis, Missouri.
MLDR, microSelectron-LDR.
122 Quality assurance in low dose-rate afterloading

It is important to note a significant treatment limita- must be obtained to verify the details of the source con-
tion with the fixed-style cable-source assembly. There is struction as well as to ensure that each source resides in
no adjustment of the source position in the applicator. the correct machine channel. A current source inventory
With manual afterloading, sometimes a spacer of length list must also be maintained as new sources are created
between 5 mm and 15 mm at the cephalad aspect of the and old ones disposed of.
tandem is used to optimize the position of the most dis- Because of the many steps involved in iridium source
tal tandem source in relation to the ovoid sources. preparation, a source preparation form is very practical
Without that option, the flange of the tandem must be to ensure that all source details are incorporated. It is
set after evaluating the sounding of the uterine depth important for a user to experiment and establish a sys-
and reviewing the source lengths that are available. tem that prepares an iridium ribbon so that, when it is
External markings on the tandem can indicate the distal finally configured, it delivers the correct active length to
extent of the available source trains for the tandem and the prescribed treatment length of the catheter or needle.
the most appropriate source train can be selected. The process of ribbon preparation can be simplified if
certain source dimensions can be kept constant, but in
many clinical situations that is not possible. Another
8.4.3 Iridium seed ribbon preparation approach for interstitial source preparation is to main-
tain a stock of fixed-length sources and vary the length of
Conventional iridium seed ribbons reinforced with the catheter or needle. However, this will cause the trans-
internal plastic filaments can be configured for remote fer tubes to have varying radii of curvature, increasing
afterloading as long as they have not been previously the likelihood of source transfer difficulties [26].
used for manual afterloading. The depth of the inner Although interstitial applications can be performed for
lumen of the implanted catheters or needles must be almost any body site, LDR remote afterloading may be
known in order to accurately position the active length at better suited for perineal and breast applications,
the prescribed treatment area. The depth information is whereas head and neck applications are generally more
determined either by pre-cutting the catheters for a con- difficult. Special attention also needs to be paid to assur-
stant inner depth or by measuring the insertion depth of ing that templates designed to hold the implanted
each catheter with a special 'measuring dummy' or com- catheters securely are also fixed securely to the patient
parable commercial measuring device. and, finally, never allow flexible catheters to be cut after
A special ribbon preparation station is necessary to the measurements for source preparation have been
prepare the source assembly safely and accurately [25]. obtained.
The process begins with trimming away any active por-
tion of the ribbon not to be used. This trimming involves
8*4*4 Treatment planning
cutting the interseed plastic filament leaving a small (2-3
mm) inactive tip that is heated with a special element to
LOCALIZATION RADIOGRAPHS
achieve a bullet-shaped tip for smooth transport. The
inactive proximal end is then cut to the length that will The localization radiographs for the evaluation of appli-
position the active length to span the prescribed treat- cator placement, the determination of applicator source
ment length. Accurate ribbon preparation must also loadings, and the computation of dose distributions are
account for the ribbon length that inserts into the con- obtained in a way similar to that used for manual after-
trol pellet and any gap between the control ball and the loading. The radiographic source markers should be
opening of the needle or catheter. The total source length inserted in the operating room once the applicators have
should be prepared so that at least 2 mm of gap is main- been secured, and the patient has arrived for simulation
tained between the ribbon tip and the inner depth limit. ready for filming. A quick inspection of the applicators is
This gap is necessary to ensure that the control pellet advised to verify that the radiographic markers are still
seats completely, enabling treatment to proceed. Clinical completely inserted. The configuration of dummy mark-
experience can help to determine the optimal gap. The ers should be documented for general reference. The
control pellet also serves as the connection for the source physicians, simulator technologists, and dosimetrists
ribbon and the drive cable. The drive-cable length con- should all be familiar with the dummy source configura-
trols the positioning of the source assembly within the tions so that, while reviewing the radiographs, errors are
shielded area when situated in the intermediate safe. not made due to misunderstanding which markings rep-
Therefore, the drive-cable length must be determined resent the actual source positions. Documentation of the
based on the sum of the active and inactive lengths of position of the dummy sources and/or actual sources
each source ribbon. Finally, the completed source assem- within applicators is also useful for reference, especially
bly is transferred from the preparation station to the for ovoids, because those dummy source markers will
source storage container, from where it is subsequently not always be distinct on lateral localization radiographs.
transferred to a channel of the intermediate safe and Figure 8.3 shows the dummy source positions in the
from there to the treatment catheter. An autoradiograph Selectron-LDR Fletcher-Suit-style ovoids and demon-
Quality assurance procedures and clinical implementation 123

Figure 83 Radiograph of the


shielded Fletcher-Suit-style
ovoid for the Selection
demonstrating the available
source positions. Positions 1-6,
indicated by the square and
round radiographic markers, are
shielded in the directions toward
the bladder and the rectum.
This radiograph can serve as a
reference for determining source
positions for dose distribution
computations because the
source positions are usually not
distinct on the lateral source
localization film.

strates that source positions 1-6 are situated between the must be evaluated before it is used clinically. Source
bladder and rectal shields. Standard active source posi- positional accuracy should be within 2 mm. Details of
tions can therefore be established, because the positions source calculation algorithms can be found in Chapter 5.
relative to the shielding are fixed. The plastic caps that The clinical evaluation of computed isodose distribu-
enlarge the ovoid diameter should be evaluated to docu- tions is no different for manual or remote afterloading.
ment the distance from the sources to the vaginal However, once the dose distributions for remote after-
mucosa and to the applicator surfaces adjacent to the loading have been reviewed and the final decisions on
rectum and bladder (which are not necessarily equal). source configuration and treatment duration have been
For interstitial applications, verification measurements documented, it may be necessary to reprogram the treat-
of catheter insertion depth should be made while the ment times or possibly modify a source configuration.
patient is in the operating room. If catheters can be pre- However, unlike manual afterloading, there is no
measured and cut to known lengths or marked in a way attempt to calculate the precise time of day the implant
that can guide precise cutting, that is a simpler process will be completed, because treatment interruptions
than measuring catheters of varying lengths. Catheters occur during the implant course for various reasons,
should extend at least 5 cm from the patient's surface to such as patient care and visitors. It has been reported
allow connection to the transfer tubes. that on average 14% more time is required to complete
the treatment, with 4% due to mechanical failures and
DOSE COMPUTATIONS the other 10% to patient care [2].
Low dose-rate remote afterloading does not require spe-
TREATMENT PRESCRIPTION
cial treatment planning equipment. The radiographs
used for source reconstruction should be obtained fol- Treatment prescriptions for remote afterloading differ
lowing whichever techniques are convenient and com- from those for manual afterloading only with respect to
patible with the user's planning system. However, if a the source types and the specification of the treatment
new planning system is obtained specifically for a remote machine. This assumes that the source activities available
afterloading system, acceptance testing of the treatment are similar to the manual sources that were used previ-
planning computer must be performed before any ously. To prescribe a Selectron treatment, a diagram of
brachytherapy dose calculations are obtained for patient the 48 available source positions for each of the three
treatments. Evaluations of treatment planning algo- channels is helpful. The physician can darken the pre-
rithms for remote afterloading have been reported with scribed active sources with ink, and the number of hours
reference to source reconstruction methods [27] and for each channel can be documented adjacent to the
dose calculation [23,24,28,29]. Results from one report source column of each channel. Figure 8.5 shows a pre-
are shown in Figure 8.4. There are several methods for scription form that was designed for both remote and
source reconstruction. The accuracy of each technique manual afterloading.
124 Quality assurance in low dose-rate afterloading

Image Not Available

Figure 8.4 Dose profiles for a single source in a Selectron applicator (profiles 1, 2, and 3) and for three sources in the applicator
(profile 4) for geometries shown in the right-hand inset. The solid profiles labeled 'a' are measured below the applicator; the dashed
profiles labeled 'b' are calculated. Profile 4b is the sum of profiles Ib, 2b, and 3b and is valid for the geometry of profile 4a except
that the attenuation effects of the stopping screw and spacers are ignored. The left-hand inset shows a correction factor to the
calculated dose for the four dose profiles. (Reprinted with permission from Conrado Pla, PhD (1987) in the International Journal of
Radiation Oncology, Biology and Physics, 13, 1761-6.)

8.5 THE ONGOING QUALITY ASSURANCE the source locations, which can allow accidental source
PROGRAM relocation to a new container position. This could only
be detected by means of the autoradiograph. Devices for
autoradiography may be commercially available, but a
8.5.1 Treatment verification simple device that secures the applicators in close con-
tact to a Ready-Pack film can be easily designed and con-
Treatment verification procedures must be performed structed. It is also possible inadvertently to connect a
for all remote afterloading treatments. The prescribed treatment tube to the wrong channel connector.
treatment is programmed by a brachytherapy technolo- Verification that source transfer tubes are connected to
gist, who refers to a copy of the physician's written direc- the corresponding treatment channels is therefore neces-
tive. A physician should check the treatment data before sary on some afterloaders. Connections should be veri-
treatment begins. The treatment verification process fied during patient connection by tracing each transfer
includes reviewing the machine console displays and tube back to the channel locking mechanism. Therefore,
printout tape, indicating source selection or configura- the ideal autoradiograph device should be capable of
tion, channel selection, and treatment duration. When detecting not only source relocations in the storage con-
applicable, the source storage container positions from tainer, but also errors in transfer tube connections. In
which sources were drawn for the prescribed channels comparison, autoradiographs of the Selectron are less
should also be checked. An autoradiograph should be likely to reveal source configuration errors that could not
obtained for each treatment so that source configuration have been detected from the machine displays or print-
or source selection can be verified for each treatment out tape, but rather, they serve primarily to document
channel and applicator. It should be noted that source correct source and spacer configuration. Autoradio-
storage containers might allow manual manipulation of graphs should be reviewed by a physicist on the same day
The ongoing quality assurance program 125

Figure 8.5 This intracavitary


prescription form was developed
at the Mallinckrodt Institute of
Radiology, St Louis, Missouri, for
remote afterloading and manual
afterloading.

that the treatment is started and filed as a source verifi- include: a review of the written directive, recalculation of
cation document. Figures 8.6 and 8.7 show two excellent any arithmetic, data transfer from tables and graphs, and
autoradiograph devices that were developed by Dr Ali correct use of data. Computer-generated dose calcula-
Meigooni and Dr Jeffrey Williamson. tions should be verified by confirming correct source
Sometimes, it is necessary to reprogram selected chan- and geometric input parameters [16]. An alternative
nels that require longer total time. If the reprogramming method compares the manual calculation of a point dose
is done during the nighttime, it may be difficult to have to the computed dose at that same point.
it double-checked. As soon as possible, the reprogram-
ming should be verified by reviewing the treatment his-
tory printout. When possible, reprogramming should be 8.5.2 Shield placement and surveys
scheduled to occur at a time when immediate verifica-
tion is possible. Prior to initiating treatment, portable bedside lead
Procedures should also be established to verify the shields should be positioned, when necessary, as indi-
dose calculations on which the treatment prescription is cated on the established floor markings or room dia-
based. Ideally, a qualified person who has not made the gram. Radiation surveys in restricted and unrestricted
initial calculation performs this check. Items to check areas contiguous to the treatment room must be
126 Quality assurance in low dose-rate afterloading

Figure 8.6 Verification of correct source selection and position for the microSelectron-LDR channels designated for the tandem and
avoids is accomplished with a special autoradiograph device (a). The three applicators can only be coupled to designated transfer
tubes and the same is true for the patient's applicators. The resultant autoradiograph (b) can be overlaid directly onto the dummy
marker film template by aligning the fiducial pinholes. The development of this device was necessary due to the possibility of
changing source positions in the storage containers which could result in an incorrect source loading. (Courtesy of Ali Meigooni and
Jeffrey Williamson.)

Figure 8.7 A special autoradiograph device (a) was


developed for the Selectron-LDR to facilitate quality
assurance testing and to verify the prescribed treatment
configuration of active cesium pellets and spacers. The 48
available source positions are indicated by the
radiographic markers and the three fiducial pinholes
enable a resultant autoradiograph (b) to overlay the
device radiograph and easily check the positions where
active sources have been sequenced. (Courtesy of Ali
Meigooni and Jeffrey Williamson.)

performed immediately after the treatment has begun to 8.5,3 Machine-testing Schedules
verify compliance with the regulations of the governing
radiological health agency. The survey results must be The AAPM [8] recommends that the quality assurance
documented, including the model and serial number of testing schedule be designed by the physicist in charge in
the survey instrument used and the initials of the person accordance with the established regulations and recom-
performing the survey. mendations, and advises that the schedule of testing be
The ongoing quality assurance program 127

frequent enough to guarantee that the equipment will system. The pressure levels that activate and terminate
work properly during a therapy session. Prior to starting the compressor cycle should be recorded. The area radi-
a treatment, the brachytherapy technologist or physicist ation monitor and its back-up battery power are checked
should perform tests to verify normal operations of crit- using a low-activity source (20-40 KBq), with the nor-
ical components and, once all tasks have been per- mal electrical power disconnected. The source transfer
formed, the treatment can be programmed and tubing should be inspected for defects and cleanliness
independently verified by the physician. A listing of daily and the applicator-transfer tube coupling mechanism
quality assurance tests is included in Table 8.8. It is use- should operate smoothly and easily. During treatment,
ful to establish a form that lists the daily test items and loose protective tubing or plastic wrapping should be
allows for the entering of the treatment date, the test used to help protect the transfer tubing from becoming
results, and the initials of the individual performing the soiled. The applicator connectors should be cleaned
tests. These daily test results should be maintained in a promptly after each treatment. While verifying the func-
special quality assurance binder and reviewed regularly. tion of the door interlock, other machine functions are
Daily air compressor testing includes checking the oil also tested, including programmability of a treatment,
level, bleeding off moisture build-up, and venting the correct response of the air compression sensors and

Table 8.8 Quality assurance review schedules for low dose-rate remote afterloaders

(Technologist) (Physicist) (Physicist)


Air compressors General Source
Area radiation monitor Key switch Leak test (semi-annual)
Paper-tape supply Channel connectors Calibration
Treatment indicator lights Coupling mechanisms Treatment-planning parameters
Door interlock Audio/visual communications Facility
Treatment interrupt switch Air compressors Radiation survey
Intercom system Room condition Area radiation detectors
CCTV system Safety CCTV system
Coupling cleanliness Operating instructions Air compressors
Treatment tubing integrity Emergency instructions Treatment device
Bedside shields positioned Radiation warning sign Main safe radiation survey
Operating instructions Regulatory agency notices Intermediate safe radiation survey
Emergency instructions Area radiation monitor
Treatment autoradiograph Autoradiograph
Functional tests Source selection
Door interlock Position in applicator
Dooroperability Complete treatment cycle
Indicator lights Safety
Audible signals Interlock systems
Bed location Power loss back-up system
Daily quality assurance log Timer linearity
Functional Air loss back-up system
Air loss test Applicator tests
Power I oss test Air leaks
Alarm indicators Ease and specificity of coupling to transfer tube
Timer versus stopwatch Total source inventory
Transit time Source and dummy positioning agreement
Time/date printout Internal shield position and dosimetry effects
Source inventory printout Temporal
Autoradiograph Timer accuracy
Correct storage locations Transit time
Correct source sequencing Dose computations
(Maintenance technician) Source para meters
Maintenance review Point dose comparisons
Complete treatment cycle
Interlock operations
Power supply voltage
Air pressure levels
Air compressor operation
128 Quality assurance in low dose-rate afterloading

valves, and treatment status indicators. Other items to the acceptance testing section. Simpler tests can be per-
check include the paper tape printer, the intercom, formed on a quarterly or monthly basis. Integrating ion-
closed circuit television system, and the accessibility of ization charge over three different time settings and
the operating instructions and emergency instructions. normalizing the charges to one time setting can check
If the outcome of any of the daily tests is not satisfactory, timer linearity. The relative charges and time settings are
the physicist should be notified to determine whether a then compared. The agreement should be within 2%.
repair is required or if the treatment must be cancelled. Stopwatch measurements should be compared to the
For example, if the door interlock is disabled, the remote machine timer and the machine calendar should also be
afterloader should not be used. checked by inspecting the date and time listed on the
Finally, just prior to treatment, the autoradiograph of treatment printout tape.
the programmed sources is obtained, the bedside shields An autoradiograph should be obtained documenting
are properly positioned, and the physician reviews the the accountability of the complete source inventory and
programmed treatment parameters and initials the that each source is located in its assigned container posi-
paper tape printout if everything is correct. Instructions tion. For devices that can sequence sources and spacers,
should be reviewed with the patient regarding the lim- the autoradiograph can also confirm correct source-
ited range of motion due to the connection to the spacer sequencing.
machine, as well as the importance of minimizing treat- A quarterly maintenance review by a qualified service
ment interruptions. With only the patient remaining in engineer is another important component of the quality
the room, the door is then closed and the treatment assurance program. However, it is very important to dis-
switch activated, sending the sources into treatment. The tinguish between different types of machine mainte-
radiation exposure in the adjacent unrestricted areas is nance, and who is authorized to perform those services.
then measured and recorded. If excessive exposure is For example, the USNRC states that authorized person-
measured, the shield position or patient position should nel are required for installation, replacement, relocation,
be rechecked and, if necessary, the adjacent areas or removal of sealed sources. In addition, any adjust-
vacated, posted, and secured. ment to any mechanism on the afterloading device,
Testing by a physicist should be done on a monthly or treatment console, or interlocks that could expose the
quarterly schedule. The frequency of the physicist source, reduce shielding around the source, or affect the
reviews should be based on machine reliability. Initially, source drive controls can only be performed by autho-
a monthly schedule is appropriate, but, if the machine rized personnel [16]. Therefore, it is necessary to clarify
performance proves to be stable and reliable, a quarterly with the appropriate regulatory agency the maintenance
schedule is justified as long as the equipment perfor- tasks that can only be performed by an authorized ser-
mance does not diminish. The items included in the vice engineer. The maintenance and repair history for
physics reviews are listed in Table 8.8. Although some of each remote afterloader should be well documented.
the tests overlap those included in the daily testing pro- Table 8.8 also includes the items to be reviewed on the
tocol, additional tests are performed to monitor machine quarterly maintenance schedule. The results of the
performance more extensively. Functional tests of the physics and maintenance reviews should be documented
device, such as response to the loss of air compression on suitable forms that are filed in the logbook designated
and electric power, are checked. These tests should be for each afterloader.
performed in a manner that ensures that any personnel On an annual basis, an in-depth physics review
radiation exposure is kept as low as possible. With the includes source calibrations, radiation surveys, applica-
physicist remaining in the treatment room, a spacer train tor tests, radiographic dummy marker evaluations, and
or a minimal number of sources is transferred into treat- treatment dose computations (see Table 8.8). It should
ment. The physicist then disconnects the air supply to also report on the source leak test results that are done at
the machine and verifies that the back-up compressed the prescribed intervals. A report is then generated based
air reservoir is activated and retracts the source train on the annual review and the treatment history for the
immediately and completely. The compressed air line is year. In addition to this extensive quality assurance test-
then reconnected and the back-up power system is ing schedule, the physicist must also determine the
checked in a similar way, by disconnecting the power appropriate tests to perform following the repair of an
cable from the wall outlet and verifying that the back-up afterloader before the device can resume clinical opera-
battery system executes the source retraction and also tion.
retains the treatment history. Once power has been The schedule of routine quality assurance and mainte-
restored, the treatment should be ready to resume with- nance testing should be based on the ongoing perfor-
out the necessity of reprogramming. During these tests, mance history of the device, and the tests to be performed
the display of the appropriate error codes and alarm should also be evaluated. The pre-treatment tests may
conditions should also be verified. reveal the most obvious machine problems, but more
Techniques for testing the timer system accuracy and subtle problems may go undetected. The more extensive
determining source transit time are described above, in quarterly tests should expose those problems. The con-
The ongoing quality assurance program 129

tent of the quarterly review should be based on the fre- A continual program of ongoing training for the staff
quency of device mishaps. Williamson [17] has reported is also very important. The device manufacturer should
that quality assurance testing rarely reveals problems provide annual refresher training, but this should be
involving accuracy of source position or treatment tim- supplemented with intramural reviews. The training of
ing, although he does acknowledge that interstitial tech- all involved personnel must include the requirement for
niques are much more complex and require more effort implementing the instructions of the authorized users,
to verify correct source positioning. However, he has consistent with the quality management program and
found that the quality assurance testing can reveal system government regulations. The training should be specific
failures involving interlocks, source transport, source or to the device model and include radiation protection
channel recognition, and back-up battery power. He has principles and practice, operating and emergency proce-
proposed a quarterly schedule for physics testing and a dures, and system design. In addition to the formal train-
quarterly schedule for maintenance review. ing in the use of brachymerapy sources that attending
physicians and residents have been given, they must also
understand how the afterloaders function so that their
8*5*4 Documentation
involvement in treatment verification, programming,
and treatment termination procedures is performed cor-
Treatment documentation can be quite extensive for
rectly. Physics procedures should also be reviewed regu-
remote afterloading. The treatment autoradiograph and
larly.
the treatment printout tape should be maintained for
The nursing staff need training in the operation of the
that purpose. The treatment tape lists the entire treat-
treatment controls as well as in interpretation of the
ment history, complete with the initial programming,
treatment status displays and the area radiation monitor.
treatment start time, treatment interruptions, error
They need to know who to contact in the event of a treat-
codes, and treatment completion time. The rest of the
ment problem as well as emergency procedures. They
treatment documentation is applicable to all brachyther-
must also understand the need to control the number
apy and includes the prescription/treatment form, com-
and duration of treatment interruptions. A videotape is
puted isodose distributions, point dose computations,
a convenient way for nurses to review these procedures.
and a dose summary report. The physician should date
Table 8.9 gives a complete listing of the items to be
and sign the written record before the treatment has
covered in an in-service training program for nurses.
begun. The record should list the radioisotope, treat-
Emergency procedures should be established that
ment site, total source strength, and exposure time or
ensure that the medical physicist or radiation safety offi-
total dose [16]. A quality assurance checklist from start
cer be notified immediately if sources fail to retract com-
to finish can also serve as a valuable document. One crit-
pletely. The names of emergency personnel and the
ical item on that checklist should document that a sur-
means for contacting them while on duty or off duty
vey was performed to verify that all sources were
should be posted at the operating console. The location
transported to the storage safe of the remote afterloader
of emergency equipment should be specified. Emergency
after the completion of treatment. The exposure rate
equipment should include a portable radiation monitor,
measured at the surface of the patient's implanted area
shielded storage containers, and long source-handling
should be recorded. It is convenient to file copies of some
tools. Supplies for removing applicators should be
of the treatment documents in a special 'Quality
Management' binder, which can be used to facilitate
internal auditing that may reveal weaknesses in the qual- Table 8.9 Nurse in-service topics for remote afterloaders
ity management program and thereby continually
Remote control button operation
improve treatment quality.
Hallway intercom operation
Utilize closed circuit TV system
8*5*5 Training personnel for remote
Procedures for patient control
afterloading
Procedures to control treatment interruptions by coordinating
with housekeeping and dietary personnel and limiting
Initially, the manufacturers of a new remote afterloading
interruptions due to visitors, clergy, and medical staff
device normally provide training for the users, opera-
tors, and supervisors of the equipment, as part of the Notify physics staff if machine error occurs (give telephone
and beeper numbers)
installation contract. The training should include appli-
cator description, the function and operation of the How to recognize a source
devices under normal and emergency conditions, all How to interpret the area radiation monitor
safety features, radiation protection procedures, sug- How to handle a dislodged source
gested quality assurance procedures and, when applic- How to use a survey instrument
able, a review of the computerized treatment planning
Radiation warnings and information posted on the room door
system [8].
130 Quality assurance in low dose-rate afterloading

readily available. In an emergency situation, the area manufacturer. A close and cooperative relationship
should be posted with radiation warning signs to prevent between the user and the manufacturer can facilitate
accidental exposures. Procedures should be carefully these improvements. This type of experience has been
designed to minimize personnel radiation exposure, reported with regard to the microSelectron-LDR [2]. A
tested regularly, and be clearly displayed at the control brief review of some of those experiences is presented in
console and the room entrance. the following paragraph so that additional insight into
Certain practical details should also be reviewed dur- the mechanics of remote afterloading can be gained.
ing personnel training. These include scheduling proce- If difficulties in source assembly transport into treat-
dures. If more than one type of remote after-loader is ment are encountered, the first thing to check is the cur-
available, the scheduling should ensure that the appropri- vature of the transfer tubing and flexible applicators,
ate machine is available for each patient. As usual, good especially at the applicator-transfer tube interface.
communication between the radiation oncologist, the Irregularly shaped source tips have also been determined
referring physicians, and the brachytherapy technologist to cause source transport problems, especially when the
is very important. Another practical point to review is source encounters a curvature just before it traverses the
that flexible interstitial catheters should never be short- transfer tube-applicator interface. This is why iridium
ened after measuring to determine the necessary active ribbon preparation includes the use of the special heat-
and inactive source lengths has been done. An undetected ing element to achieve a smooth, bullet-shaped, plastic
shortened catheter will result in either a source position- tip-
ing error or a source transfer alarm condition. One final Other difficulties have been associated with flexible
practical point is that applicator openings should always catheters used for perineal implant sites. Flexing or con-
be capped to prevent fluid or dirt from getting inside. The stricting of the catheters will result when the patient
applicators should only be uncapped when inserting or shifts position in the bed or sits up. This may cause
removing dummy sources and when connecting to the source assemblies and drive cables to uncouple during
transfer tubes for treatment. Foreign material, if carried source retraction, leaving the sources in the catheters. An
by the source or source assembly into the afterloader inte- alarm condition will occur. By inspecting the machine
rior, can damage optical sensors and cause premature console display, the errant channels can be identified.
mechanical deterioration. The patient's position should be adjusted to relieve the
It is the responsibility of the physicists and pressure exerted on the catheters so that source recovery
brachytherapy technologists to schedule and provide the can be undertaken. The transfer tube should be uncou-
ongoing training. The reviews must be given to all pled at its connection to the intermediate safe and a
involved personnel at least once per year and promptly source recovery tool passed down the transfer tube to
for new staff. A reference binder containing descriptions retrieve the source assembly and return it to the source
of established procedures and instructions for all storage container. This problem can be minimized if the
involved personnel should be readily available at the patient's position is kept at a low angle in the bed. The
afterloader treatment areas (Table 8.10). patient can be instructed via the intercom to assume this
position just before source retraction is activated. The
use of rigid implant needles should also reduce the fre-
8*5.6 Practical operational considerations
quency of this problem. These corrective actions can also
be used to facilitate source transport into treatment.
The introduction of new brachytherapy technology not
Obviously, the audible alarm system is very important in
only demands that new treatment procedures be estab-
afterloaders.
lished, but sometimes also requires modification of cer-
Strengthening the connection of the drive cable to the
tain design features of a new device in order to achieve
source assembly has also been attempted to prevent
smooth operation in the field. Some of these issues can
uncoupling. This may be a reasonable solution if the
be resolved by further product development by the
same source assemblies are used routinely, but requires
that those sources be stored indefinitely in the interme-
diate safe. However, this approach exposed a malfunc-
Table 8.10 Contents of a procedures manual available at the
tion that otherwise might have never been detected. On
nurses'station
occasion, sources in the intermediate safe that were not
Procedures for machine programming and initiating programmed for treatment would actually be trans-
treatment ferred into treatment along with the programmed
Procedures for uncoupling and terminating treatment sources, even without an applicator or transfer tube in
Procedures for cleaning treatment tubing and connectors place. The discovery of that malfunction forced those
Emergency procedures
treatment machines to be removed from clinical service
until the problem was corrected.
Error codes, their interpretation, and corrective actions to be
Another potential problem involves perineal applica-
taken
tions. When the patient adjusts his or her position in the
References 131

bed, the applicator system can become dislodged. This is intravaginal brachytherapy. Int.J. Radial Oncol. Biol.
caused by the patient moving away from the transfer Phys., 26(3), 499-511.
tubing without the tubing being free to follow, as in the 6. Glasgow, G.P. (1989) An inventory of cesium-137 seeds for
situation in which the patient inadvertently places one multiple site interstitial brachytherapy with a
foot over the tubing while adjusting position. It is essen- microSelectron. Endocuriether. JHypertherm. Oncol., 5,
tial that the applicator systems be adequately secured to 175-9.
the implant site, and the patients also need to be 7. US Nuclear Regulatory Commission (1993) Title 10
reminded that they are tethered to the treatment Chapter 1, Code of Federal Regulations-Energy, Part 20:
machine and care must be taken to avoid applying forces Standards for Protection Against Radiation. Washington,
that can disengage the implant systems. The nurses and DC, Government Printing Office.
physicians should regularly check the source transport 8. Glasgow, G.P. (1993) Remote Afterloading Technology,
tubing to prevent tangles and to verify that the applica- Report of the American Association of Physicists in
tor system has not become dislodged. Medicine Task Group No. 41. New York, American
Although not all remote afterloaders are plagued with Institute of Physics.
all the problems described above, a functional problem is 9. Klein, E.E., Grigsby, P.W., Williamson, J.F.etal. (1993) Pre-
always possible due to the number of treatment inter- installation empirical testing of room shielding for high
ruptions over the long duration of the treatments. dose rate remote afterloaders. IntJ. Radial Oncol. Biol.
Certain personnel, generally physicists, must be assigned Phys., 27(4), 927-31.
to respond to a machine failure at any time so that these 10. National Council on Radiation Protection and
treatment-related problems can be resolved quickly and Measurements (1976) Report No. 49: Structural Shielding
safely. The nursing staff cannot be expected to be Design and Evaluation from Medical X-rays and Gamma
responsible for this, although sometimes only a tele- Rays of Energies up to 10 MV. Bethesda, Maryland,
phone call to the physicist on call is necessary to resolve National Council on Radiation Protection and
a relatively simple problem. Measurements.
The adjustments that one must make for remote after- 11. Pipman.Y., Jamshidi, A. and Sabbas, A. (1989)
loading are related to the new source types, the changes Commissioning of a Selectron LDR remote afterloader
in the control of source placement and treatment timing, tests and measurements (Abstract). Med. Phys., 16(3),
the fact that the patient is tethered to a machine, and the 494.
uncertainty of not knowing exactly when the treatment 12. Jones, C.H. (1990) Quality assurance in brachytherapy.
will be completed. One must realize that reliance on a Med. Phys. World, 6,4-11.
machine to control a treatment requires a comprehen- 13. Mesina, C.F., Ezzell, G.A., Campbell, J.M. etal. (1988)
sive quality assurance program and ongoing training Acceptance testing for the Selectron high dose rate
and, despite it all, there will inevitably still be machine remote afterloading cobalt-60 unit. Endocuriether./
failures at some time. Hypertherm. Oncol., 4,253-6.
14. Slessinger, E.D. (1990) A quality assurance program for
low dose rate remote afterloading devices. In
Brachytherapy HDR and LDR, ed. A. Martinez, C. Orton
REFERENCES
and R. Mould. Columbia, Maryland, Nucletron
Corporation, 160-8.
1. Nath, R., Anderson, LL, Meli, J.A., Olch, A.J., Stitt, JA and 15. Slessinger, E.D. (1990) Selectron-LDR quality assurance.
Williamson, J.F. (1997) Code of practice for brachytherapy Selectron Brachy therapy J., 4(2), 36-40.
physics: Report of the AAPM Radiation Therapy Task 16. Idaho National Engineering Laboratory (1994) Quality
Group No. 56. Med. Phys., 24,1557-98. Management in Remote Afterloading Brachytherapy. US
2. Grigsby, P.W., Slessinger, E.D., Teague, S.P. etal. (1995) Washington, DC, Nuclear Regulatory Commission.
Clinical evaluation of an interstitial remote afterloading 17. Williamson, J.F. (1991) Practical quality assurance in low-
device for multichannel intracavitary irradiation. Int. J. dose rate brachytherapy. In Quality Assurance in
Radial Oncol. Biol. Phys., 31(4), 875-81. Radiotherapy Physics: Proceedings of an American College
3. Grigsby, P.W., Williamson, J.F. and Perez, C.A. (1992) of Medical Physics Symposium, ed. G. Starkschall and J.
Source configuration and dose rates for the Selectron Morton. Madison, Wisconsin, Medical Physics Publishing
afterloading equipment for gynaecologic applicators. Int. Company, 139-82.
J. Radial Oncol. Biol. Phys., 24(2), 321-7. 18. Meigooni.A.S., Williamson, J.F. and Slessinger, E.D. (1993)
4. Wilkinson, J.M., Moore, C.J., Motley, H.M. etal. (1983)The Practical quality assurance tests for positional and
use of Selectron afterloading equipment to simulate and temporal accuracy of HDR remote afterloaders.
extend the Manchester System for intracavitary therapy Endocuriether./Hypertherm. Oncol., 9,46.
of the cervix uteri. Br.J. Radio!., 56(666), 409-14. 19. Thomadsen, B.R. (2000) Quality management for low and
5. Sloboda, R.S., Pearcey, R.G. and Gillan, S.J. (1993) medium dose rate afterloaders. In Achieving Quality in
Optimized low dose rate pellet configurations for Brachytherapy. Bristol, IOP Publishing.
132 Quality assurance in low dose-rate afterloading

20. International Electrotechnical Commission (1989) J.F. Williamson, B.R. Thomadsen and R. Nath, Medical
International Standard IEC 601-2-17 Medical Electrical Physics Publishing, Madison, Wl, 503-22.
Equipment Part2. Geneva, Bureau Central de la 26. Slessinger, E.D. (1995) Clinical implementation of LDR
Commission Electrotechnique International. remote afterloading. In Brachytherapy Physics, ed. J.F.
21. Orton, C.G. and Siebert, J. (1972) Instrument non-linearities Williamson, B.R. Thomadsen and R. Nath, 521^0.
and therapy unit timer error. Phys. Med. Biol., 17,198-205. 27. Slessinger, E.D. and Grigsby, P.W. (1989) Verification
22. Williamson, J.F. (1986) The accuracy of the line and point studies of 3D brachytherapy reconstruction techniques,
source approximations in 192lr dosimetry. Int.J. Radial in Brachytherapy 2, ed R.F. Mould. Leersum, The
Oncol. Biol. Phys., 12(3), 409-14. Netherlands, Nudetron Trading BV, 130-5.
23. Siwek, R.A., O'Brien, P.F. and Leung, P.M.K. (1991) 28. Meertens, H. and van der Laarse, R. (1985) Screens in
Shielding effects of Selectron applicator and pellets on ovoids of a Selectron cervix applicator. Radiother. Oncol.,
isodose distributions. Radiother. Oncol., 20(2), 132-8. 3(1), 69-80.
24. Pla, C, Evans, M.D.C. and Podgorsak, E.B. (1987) Dose 29. Steggarda, M.J., Moonen, L.M., Damen, E.M. and
distributions around Selectron applicators. Int.J. Radial Lebesque, J.V. (1997) An analysis of the effect of ovoid
Oncol. Biol. Phys., 13(11), 1761-6. shields in a Selectron-LDR cervical applicator on dose
25. Slessinger, E.D. (1995) Commissioning of non-stepping distributions in rectum and bladder. Int.J. Radial Oncol.
source remote afterloaders. In Brachytherapy Physics, ed. Biol. Phys., 39,237-45.
9
Quality assurance in high dose-rate afterloading

COLIN H.JONES

9.1 INTRODUCTION subject has been considered by several groups [3-5].


Chapter 8 describes the quality assurance measures
required in low dose-rate (LDR) afterloading. Many of
A quality assurance program should give assurance to these measures apply equally well to high dose-rate
the user that predetermined specific objectives are being (HDR) procedures, and the contents of both chapters
met. There are two fundamental requirements in may be considered to be complementary to each other.
brachytherapy and these are: first, to deliver a prescribed There are four important elements which are com-
radiation dose within acceptable limits of accuracy; and, mon to quality assurance programs:
second, to ensure that, in so doing, patient, staff, and
public are not irradiated unnecessarily. The uncertainty 1. The appointment of a person experienced in
in dose specification can be subdivided into that due to radiation physics to be responsible for drawing up
clinical procedures, such as the uncertainty in the indi- the quality assurance program, for training staff, and
cation of the target volume on a localizing radiograph, for ensuring compliance with the program.
and that due to physical procedures. The latter is princi- 2. The program should be documented in detail,
pally the uncertainty in dose determination due to cali- including the procedures which must be followed,
bration of the source and dosimetric calculations. The the tests which must be carried out, and the
Netherlands Commission on Radiation Dosimetry frequency of these tests. The results of these tests in
(1991) recommended that the uncertainty in the dose terms of compliance or non-compliance should be
specification due to these physical procedures (defined recorded.
as one relative standard deviation) should be less than 3. Radioactive sources should only be used in
5%. This is consistent with the recommendations of the compliance with local, or national and/or
International Commission on Radiological Protection international recommendations.
(ICRP) [1] and the World Health Organisation [2]. In 4. Incidents which have, or might have, affected the
the USA, the Nuclear Regulatory Commission (NRC) precision of treatment or the safe use of sources
define a misadministration as a dose differential of 20% should be noted: the program can then be modified
between the prescribed and administered doses; a dose in the light of experience. The overall program
delivered to the wrong treatment site is also considered should be reviewed periodically.
to be a misadministration. In order to achieve a high Quality assurance for remote afterloading devices
level of accuracy and to minimize radiation exposure with HDR sources are considered here under the follow-
beyond the treatment volume, it follows that a quality ing headings:
assurance system must cover every aspect impinging
upon the treatment of the patient and that each part of 1. Regulatory requirements
the treatment process should be evaluated critically. The 2. Facility design
134 Quality assurance in high dose-rate afterloading

3. Machine function tests each group of channels where channels are grouped to
4. Tests relating to treatment precisions operate together. Furthermore, controlling timers must
5. Quality assurance documentation. have a mean percentage average error not exceeding 1. In
order to comply with these requirements, it is necessary
to undertake appropriate tests and these must form part
of a quality assurance program.
9.2 REGULATORY REQUIREMENTS
International regulatory requirements are designed to
ensure that, when equipment is used in compliance with
Remote-controlled, automatically driven, gamma ray these standard recommendations, radiation hazards are
afterloading equipment is made and finished with a minimized and treatment delivery can be achieved safely.
degree of uniformity and manufacturers are required to Clearly, good radiation protection practice consistent
comply with generally accepted principles of sound and with regulatory requirements should be part of the
safe practice. This applies to the radiation source and to quality program.
all components of the equipment, including, for exam-
ple, any programmable electronic system used as a con-
trolling timer, or any interlocks that are used in the 93 FACILITY DESIGN
equipment. Consequently, the machine features
designed by different manufacturers are often similar
High dose-rate brachytherapy covers a wide range of dif-
and quality assurance procedures required for different
ferent kinds of treatment, including the use of surface
types of remote afterloading equipment are correspond-
moulds, intracavitary and interstitial techniques using
ingly of a common nature. The fabrication of the
HDR treatments and pulse dose-rate (PDR) treatments.
radioactive source and its containing capsule must con-
The duration of a treatment might range from a few
form with BS 5288 in the UK and the source housing
minutes, as in the case of conventional HDR treatments,
within the equipment must conform to regulatory
to a few days for PDR treatments. Although it is possible
requirements. The International Standard IEC
to install an HDR machine in a modified radiotherapy
601-2-17 [6] specifies the requirements with regard to
treatment room, it is better to install such equipment in
the design, function, testing, and use of remote after-
a room designed specifically for the treatment tech-
loading equipment. This standard specifies requirements
niques envisaged.
for equipment which gives air kerma rates up to
The details of the design brief for such a room will
500 mGy rr1 at 1 m from the radioactive source or
depend upon the type of brachytherapy being planned.
sources in use. For equipment operating outside this
There are, however, various considerations that are com-
range, special precautions may be necessary. In the UK,
mon to most requirements:
the use of such equipment is also covered by the Ionising
Radiation Regulations [7]. In the USA, the NRC specifies The treatment room should be constructed to allow
a number of requirements with regard to the design, safe implementation of the prescribed treatment.
function, testing, and use of such equipment. The room should have sufficient shielding or be so
The IEC Standard 601-2-17 [6] specifies require- isolated that healthcare personnel, patients, and
ments for equipment intended to be: used under the members of the public will not receive incidental
supervision of qualified persons, maintained at predeter- radiation exposure in excess of recognized specified
mined intervals, and subjected to regular checks by the limits. The radiation levels in and around the room
user. The requirements of the standard are based on the should be measured or calculated and staff working in
assumptions that an irradiation treatment prescription the area should be monitored. Areas where the dose
is available which prescribes appropriate values of the rate is more than 7.5 uvSv h'1 should be designated as
treatment parameters and the air kerma rate at 1 m from controlled areas: a supervised area where the dose rate
the radioactive source(s) in the equipment is known. is less than 7.5 (iSv h-1 but more than 2.5 |lSv h-1 might
These requirements are intended to ensure that the pre- in some circumstances also be identified. Radiation
scribed values of the treatment parameters can be warning notices should be posted identifying the
achieved by the equipment, in particular that the controlled area.
selected radioactive source (or sources) is positioned or The layout of the room should allow patients to be
moved within the source applicator in the selected con- nursed safely, efficiently, and with as little
figuration relative to the source applicator. The indica- inconvenience and discomfort to the patient and staff
tion that the position of any source or source train as possible and also allow all the procedures
within an applicator supplied with the equipment is to associated with the medical care of the patient to be
be as selected will not be given unless such positions are accomplished.
within 2 mm of those programmed, in any direction. It The room should be equipped so that any necessary
is a requirement of the standard that the equipment is medical emergency procedures can be implemented
provided with a controlling timer for each channel or speedily and effectively.
Facility design 135

Particular attention should be paid to the need for The room should be equipped with the following:
coping with radiation emergencies that might occur
during the course of treatment. Closed circuit television (CCTV) cameras with
monitors at the control console: it is preferable that
It is important that the radiation protection adviser one of these systems should be in color so that the
and/or experienced radiation physicist should be patient's clinical appearance can be viewed
involved in the room design concept at an early stage in satisfactorily.
the planning process. HDR sources are principally either Two-way patient intercommunication.
cobalt-60 or iridium-192. In both cases, the high dose Radiation warning lights: these should be fitted inside
rates associated with the high-activity sources necessitate the treatment room, at the door entrance, and at the
a room design which has either some form of maze control console, and should be activated when the
entrance or a very heavy lead door. HDR treatment radiation source is exposed. Controlled area signs
rooms require walls of thickness 40-60 cm of concrete, should be posted to indicate areas where the dose rate
depending upon the size of the room and the energy and is greater than 7.5 (J,Sv h-1; these signs should
activity of the sources that are being used. Table 9.1 lists preferably be linked to the machine so that they will
the physical characteristics of cobalt-60 and iridium- be illuminated when the radiation sources are
192. In practice, a room with a maze-type entrance exposed.
requires more floor space, but allows economies to be It is advisable to use an audible time delay interlock so
made in terms of cost and convenience. If adequate space that the machine can only be switched on within a
is available, it is also advantageous to include some form predetermined time after the time delay has been
of X-ray facility within the room so that applicator posi- activated: the time setting should be adjusted so that
tions can be checked prior to treatment without the need this is optimal, giving just sufficient time for
for moving the patient. Protective lead doors and also personnel to leave the treatment room and initiate
any barrier to the maze entrance must be interlocked treatment.
with the treatment unit. There should be an independent audible radiation
A comprehensive radiation protection survey should alarm inside the treatment room.
be made prior to using the facility and this should be kept Near the treatment console, there should be a hand-
for reference purposes: if alterations are made subse- held dose-rate meter and a personal integrating dose
quently to the room structure or layout, these should be meter for use in emergencies.
recorded and the survey repeated. The air kerma rate Within the treatment room, there should be a
around the source storage container should also be sur- shielded safe, which should be available for storing the
veyed. At any position 50 mm from the surface of the radioactive source(s) in the event of an emergency or
storage container or any other surface permanently fixed when the machine is being serviced.
to it, the air kerma rate mSv should not exceed There should be a clearly labelled 'emergency stop'
0.01 |0,Svh-1.The air kerma rate at any position 1 m from adjacent to the console.
the surface of the storage container should not exceed If a diagnostic X-ray unit is available within the
1 (iiSv h-'. It is a requirement of the IEC standard that treatment room for localizing radiographs, warning
these measurements should be made with the combina- lights should indicate when this machine is being
tion of radioactive sources that is possible within the used and there should be adequate radiation
specifications given by the manufacturers and is the least protection for the operator.
favorable with regard to the magnitude of the dose rates.
For measurements at 50 mm, the air kerma rate should be Many of these items will require checking at regular
averaged over an area up to but not exceeding 10 cm2; for intervals as part of a quality assurance program.
measurements at 1 m, the air kerma rate should be aver- HDR equipment should not be used as mobile equip-
aged over an area up to but not exceeding 100 cm2. The ment. In the USA, the NRC requires licensees to comply
room containing the source safe should be lockable so with the above requirements, and relocation of the remote
that access is restricted when the machine is not in use. afterloading device to another area is prohibited without

Table 9.1 Properties of principal brachytherapy nudities

"Co 5.27 years 1.17,1.33 309 12 40 206


92
lr 74 days 0.3-0.6 113 4.5 15 113
HVT = half value thickness; TVT = tenth value thickness.
136 Quality assurance in high dose-rate afterloading

prior NRC approval. The dedicated treatment room must the shielding of the source safe complies with
be equipped with continuous viewing and intercom sys- regulatory requirements.
tems to allow for patient observation during treatment With the source exposed, exposure rates in accessible
and, if the systems do not have a back-up system to be areas outside the treatment room should be
used if the primary system fails, the licensee must commit measured. The maneuverability of the unit should be
to suspending treatments until the primary system is taken into account: in small treatment rooms it might
repaired. In common with the IEC requirements, the be possible for the machine to be near to the
NRC specifies that areas or rooms used to store remote treatment room door, which could result in high dose
afterloading devices or source containers housing a rates outside the room. On the basis of the predicted
source must be secured; dedicated treatment rooms must workload, it will be necessary to calculate the monthly
have an electrical interlock system and restricted area con- radiation exposures to staff operating the machine to
trols. If there are other radiation-producing devices ensure that the dose levels are acceptable.
located in the treatment room, the licensee must institute The user is required to estimate the dose delivered to
mechanisms to ensure that only one device can be placed the patient during transit of the radioactive sources
in operation at any one time. into the treatment position. Transit doses are partly
determined by the time taken by the transit
movements, but they are also determined by the
9.4 MACHINE FUNCTION TESTS strength of the radioactive sources selected by the user
and by the number of interruptions during treatment.
To calculate the total transit dose, it is necessary that
The function of the remote afterloading device should
the user has information from which the transit doses
be evaluated before the radioactive source is installed.
may be estimated and takes appropriate account of
When possible, a number of tests should be performed
them. The IEC standard relates to measurements or
with a dummy source substituted for the actual source to
calculations for two conditions for each channel: the
test the source drive mechanism and safety interlocks.
air kerma at a position 20 mm from the axial center of
These tests should include the following:
the source applicator, and the air kerma at a position
All door and safety interlocks. 1 m from the axial center of the channel. For each
Emergency return mechanisms. condition, the air kerma should be measured or
Controlling timers. calculated for one specified radioactive source and
The security of couplings and connections. should be at the positions that are least favorable with
Catheters and any other accessories that are going to regard to this requirement. For measurements at
be used during treatment should be checked to ensure 20 mm the air kerma should be averaged over an area
that all have closed ends so that the radioactive source of up to but not exceeding 2 cm2, and for
cannot be lost within a patient should source measurements at 1 m the air kerma should be
encapsulation fail. averaged over an area up to but not exceeding
The limitations of channels and source applicators must 100 cm2.
be tested and documented: in practice, acute directional In the event of an emergency, it might be necessary for
changes of source transfer tubes should be avoided to a user to enter the treatment room with the source in
prevent 'sticking' of the source in transit, and it is useful the exposed position. It is useful to have knowledge of
to carry out such tests using a dummy source. the radiation distribution inside the treatment room
The operation of the door warning lights, CCTV so that the line of entry can be optimized to reduce
systems, intercoms, and the audible time delay personnel exposure.
interlock should be checked for function and also The radiation monitor used to check dose rates
adjusted to work optimally. outside the treatment room and also inside the room
The console display should be checked: test all button and around the machine should be tested over the
functions by programming and carrying out a entire range of radiation levels that might be present.
simulated treatment; verify that all displays are Some monitors will saturate and fail if directly
correct; verify that the data on any printout agree with exposed to high dose rates, so it is appropriate to use a
the programmed data; and, when appropriate, check survey instrument with a wide range from 1 mSv tr1
program card data input function. to at least 1000 mSvh-1.
Although remote afterloading devices make use of
Once the radioactive source has been installed into the
radioactive sources in a sealed system, users are
treatment device, the above tests should be repeated in
obligated to check for leakage and/or contamination
addition to the following tests:
of the source. It is not possible to check for
With the source in its safe position, a survey should be contamination directly and it is therefore appropriate
made with a portable radiation dose-rate meter periodically to check the catheters through which the
around the remote afterloading device to ensure that radioactive sources pass. Sometimes, in the
Tests relating to treatment precision 137

preparation of encapsulating the source, radioactive 1. single HDR iridium-192 source machines
contamination adheres to the source capsule and it is 2. PDR single HDR iridium-192 source machines
appropriate to check for this free radioactivity by 3. machines that have multiple HDR cobalt-60 sources.
passing the source through a catheter several times
and then checking for any radioactivity with a Details of these machines are shown in Table 9.2.
sensitive radiation detector capable of detecting less Whereas the majority of quality assurance checks are
than 200 Bq. common to all systems, some of the design features are
The radioactive source should be calibrated and the different and allowance has to be made for such varia-
strength of the source (or sources) should (when tions in the quality assurance program that is adopted.
appropriate) be entered into the treatment machine. These may be summarized as follows:
The output from the printer should be checked to
In the case of single HDR iridium-192 source
ensure that the correct source activity is displayed
machines, the high-activity source is physically very
and, if the machine corrects automatically for source
small and attached to a cable which is driven by a
decay, it will be necessary to check that this
stepping motor so that the required radiation
calculation is within acceptable limits.
distribution can be achieved. The half-life of iridium
is relatively short, so the source has to be changed at
approximately 3-monthly intervals. The physical
9,5 TESTS RELATING TO TREATMENT
characteristics of the radioactive source are such that
PRECISION
very fine catheters can be used, with the result that
very high local doses are given to tissues surrounding
Accurate delivery of doses using HDR systems depends the catheters. Precise control of the stepping motion is
on knowing the strength of the radioactive sources at the necessary if reliable radiation distributions are to be
time of treatment (see Chapter 3), the precision and con- achieved. The length of the cable to which the source
sistency of the timer, and the ability of the treatment is attached must be constant and when sources are
machine to position the source at the proper location replaced it is necessary to check that this length has
along the catheter or treatment applicator. not altered. Providing the stepping function of the
Reference has already been made to the requirement machine works satisfactorily, then reliably high
that the equipment should provide a controlling timer precision radiation treatments can be achieved. The
for each channel which should have a mean percentage versatility of the machine allows a wide range of
average error not exceeding 1. Timers should be checked different types of treatments to be achieved, including
by selecting five pre-set times (not smaller than 1% of those using applicators, needles, and catheters. The
the maximum pre-setable time) to cover the range pos- position of the source within these treatment devices
sible with the treatment device - taking the mean per- must be checked before clinical use. When the source
cent average error at the five pre-set times. In practice, is changed, different tests must be carried out to
some equipment manufacturers arrange for these tests to ensure that the catheter length has not been altered in
be carried out as part of a routine maintenance contract. any way.
Even so, it is important for the user to recognize that Several different commercial HDR iridium-192
such tests have to be made. Timer errors can occur [8]. source machines are commercially available and
Likewise, machines that use a single source which can be such equipment has largely replaced multiple-source
programmed into a number of dwell positions should be HDR devices.
checked to ensure that the programmed dwell times are PDR single HDR iridium-192 source machines also
within the required precision. use a stepping source, but are designed specifically to
Before describing specific quality assurance tests, it is use a lower activity source and to deliver the radiation
appropriate to mention that there are three principal cat- dose over a much longer period of time. For example,
egories of HDR equipment. These are: a treatment might consist of 30-40 fractions over a

Table 9.2 Details of sources used in remote afterloading equipment

192
HDR lr 400 1 Cylinder 1.1 Cable
192
PDR lr 20-40 1 Cylinder 1.1 Cable
HDR 60Co
4-20 20 variable Pellet 2.5 Pneumatic; cable

HDR = high dose rate; PDR = pulsed dose rate.


138 Quality assurance in high dose-rate afterloading

period of 3-5 days or maybe the dose will be delivered


with a series of fractions given each hour throughout
the day. The technique that is used might vary from
one center to another and, in some situations, it is
possible to disconnect the treatment machine from
the patient to allow the patient greater comfort during
the period when radiation is not being given. The use
of multiple fractions over a longer period of time can,
in some circumstances, be logistically difficult and it is
important to ensure that appropriate quality
assurance measures are adopted to prevent
applicators within the patient being displaced. This is
especially so when patients are disconnected from the
machine and then recoupled to the machine many
times over the treatment period. One very important
consideration of PDR brachytherapy is the safety Figure 9.1 Part of a radiographic marker (magnified) for HDR
aspect. Based purely on health and safety (MDR) Nudetron Selectron showing 'stacking' of dummy source
considerations directly related to the instantaneous pellets in photograph (a) in comparison with photograph (b).
exposure rate from PDR machines, it is necessary to
ensure the continuous availability of a trained person
during the delivery of the radiation dose. Should the each day of use and that the precision of reproducibility
device fail with or without alarm generation, due should be within 1 mm.
either to mechanical failure or facility power failure, The techniques can be used separately or conjointly to
the dose delivered to the patient could be considerable provide information about the distribution of radioac-
unless immediate removal of the source by manual tive material within the source container and positional
means by an experienced member of staff can be information about individual sealed sources in treat-
achieved. Other quality assurance measures are similar ment trains.
to those for a conventional HDR treatment machine. The autoradiography technique is simplified by hav-
HDR machines using multiple sources of cobalt-60 ing a PMMA or wax support which has a recess with the
are similar in design to LDR or medium dose-rate same dimensions as the source (Figure 9.2). Auto-
multiple source cesium-137 machines and the quality radiographs are useful for checking the uniformity of
assurance measures are similar to those described in radioactivity and are also a useful means of checking
Chapter 8. The source catheter is made up of active the relative strength of individual sources in a source
sources and inactive spacers and the size of each of train. Visual inspection of the autoradiograph might
these is greater than that of the cable-driven source. indicate lack of uniformity at the 10% level, but for more
The sources and spacers are spherical and driven reliable assessment, densitometric scanning is to be pre-
pneumatically from a treatment safe into a specially ferred.
designed treatment catheter. Stacking of sources In the case of positional studies, it is useful to incor-
occurs in a similar way to that shown in the porate lead markers into the wax support: secondary
radiograph of the dummy source train in Figure 9.1.
The fact that there are multiple sources means that
there is a range of source activity and there is no
control over which source is used for a particular
treatment. The consequence is that the precision with
which radiation doses can be delivered using such a
system is less than that for a single high-activity
stepping source.

9.5*1 Positional reproducibility

Sources used inside applicators, catheters, and needles


should be autoradiographed and radiographed. This is
to establish the precise location of the source with
respect to the end of the applicator and to check the
machine functions. The NRC requires that the repro-
ducibility of the source positioning should be checked Figure 9.2 Wax disc for applicator and source autoradiographs.
Tests relating to treatment precision 139

electron emission from the lead results in an autoradio-


graph of the markers and provides the required posi-
tional data. This is particularly useful for checking the
position of sources loaded into applicators or catheters,
for which it is sometimes difficult to identify the precise
end or tip. The method allows precise comparison to be
made with different applicators and provides a record of
the location of the radioactive sources inside loaded
applicators (Figure 9.3). Envelope-wrapped Kodak
X-Omat Verification film is suitable for these studies.
Uniform pressure should be maintained over the film
and source to keep both in close contact.
For high-activity sources such as those used in HDR
equipment, film exposure is only a fraction of a second
and is suboptimal because the transit time is of compara-
ble magnitude. Gafchromic film is a useful alternative.
This is a thin radiation film which is colorless, grainless,
and offers high spatial resolution (1200 line pairs mm'1).
When exposed to high doses of radiation, typically
200 Gy, a dye in the film turns blue - the density of which
depends upon the absorbed dose. This means that expo- Figure 9.3 HDR microSelectron source autoradiograph showing
sures of about 20 s are required for autoradiography, position of source in relation to top of applicator.
which results in better control of the image quality. The
film is not light sensitive and produces high-quality
images. Figure 9.4 illustrates the response of Gafchromic
film to iridium-192 radiation, and Figure 9.5 illustrates a
multiple exposure of an HDR iridium-192 source in a test
jig designed for the measurement of source position [5].
Detex paper is a cheaper alternative to Gafchromic.
This paper is used in the printing industry and changes
color when exposed to high radiation doses. Before
exposure, the paper is yellow, but under irradiation,
hydrochloric acid is released from the ink and the yellow
azo dye turns red. The shade of red does not indicate the
dose, but rather that a certain level of dose has been
achieved. Detex labels, for example, are used to indicate
whether a product has received a sterilizing dose of radi- Figure 9.4 Density-dose response curve for Gafchromic exposed
ation. Detex paper can be used in situations in which the to iridium-192 source, using light of wavelength 600 nm.
dose falls within 1-100 kGy.

Figure 9.5 (a) Photograph of


test jig. (b) Autoradiographs of
HDR iridium-192 source in test
jig-
140 Quality assurance in high dose-rate afterloading

In summary, autoradiography forms an important program used to determine the geometrical configura-
part of commissioning and quality assurance and may be tion of the sources should also be checked.
used to: In estimating the overall accuracy of a particular tech-
nique, some estimations should be made of the likeli-
examine the distribution of radioactivity in the source
hood of source displacement which might occur during
capsule or the distribution of activity amongst
the course of treatment.
sources
In the case of HDR machines with a single source, the
record the position of the source with respect to the
location of the source can be determined by alternative
end of the transfer cable
methods. The simplest of methods is to use a video cam-
record the relative position of each individual source
era system, a transparent plastic applicator, and a linear
in a source train
scale.
check the reproducibility of source positions when
On a daily basis, a check ruler (such as that available
inserted into catheters, needles, or applicators. It is
for the HDR microSelectron) may be used to check the
important that every such device which is used
accuracy of source positioning. The ruler is attached to
clinically should first be tested and the
the treatment unit through a treatment transfer tube. It
autoradiographic test data should be used as a
consists of a scale and a marker rod, which is moved by
baseline for subsequent quality assurance
the source cable as it moves along the ruler. One can
investigations.
evaluate the motion of the source by checking the posi-
There is also a place for X-ray radiography in quality tion of the rod against the programmed position of the
assurance. For example, it is necessary to check the spa- source. However, the technique only indicates the
tial distribution of sources in the patient for dosimetry motion of the end of the marker rod.
purposes and this might require the use of radiographic Speiser and Hicks [9] have modified a check ruler to
markers. These markers are inserted into empty applica- incorporate a diode radiation detector which indicates
tors prior to loading the radioactive sources into the source position (Figure 9.7). The diode is a 1 mm2 pho-
patient so that the geometrical position of the applica- todiode placed within a few millimeters of the source
tors can be located accurately. In the course of commis- path. Its position corresponds to a fixed distance from
sioning new equipment, radiographic checks should be the treatment head. The diode is connected via coaxial
made to ensure that these markers are reproducible and cables to an electrometer. As the source gets near the
that their position within a set of applicators is clearly diode, the reading on the diode increases. The electro-
defined in relation to the radioactive sources. The repro- meter readings can be correlated to source position with
ducibility of a set of markers should be within 1 mm an accuracy of 0.1 mm. The authors found this accuracy
(Figure 9.6). sufficient to detect differences in length of transfer tubes,
The precision of the method used to localize the as well as the variation of path lengths with relaxation or
inserted sources should be checked for each type of tech- change of curvature of the transfer tube.
nique to be used. The accuracy of the reconstruction As part of the basic equipment package, some manu-
facturers include a 'QA Physics Package.' This comprises
a well chamber and an electrometer for calibrating the
radioactive source, a camera and scale assembly, which
enables the source wire to be imaged against a scale at
specified distances of source travel. One such system is
the VariSource (manufactured by Varian Oncology
Systems) remote afterloading machine. A frame-grabber
captures the images of the calibration device and dis-
plays the position of the source wire on the VariSource
computer monitor (Figure 9.8). The system is conve-
nient to use and takes only 3 min to check and, if neces-
sary, recalibrate the drive positioning system and to
obtain an automatic printout for quality assurance
records; consequently, this can be done prior to each use
of the machine.
A well-type ionization chamber can also be used for
checking the source position at the end of a transfer
cable. By means of a specially designed quality assurance
insert which fits into the well of the ionization chamber,
it is possible to test not only source positioning but also
Figure 9.6 Radiographs of markers in HDR (MDR) Nudetron the timer and its consistency. Quality assurance inserts
Selectron applicators showing relative positions of sources. for use with the Standard Imaging well chamber have
Tests relating to treatment precision 141

Figure 9.7 Top and side views of modified check ruler as described by Speiser and Hicks [9].

been described by Jones [10] and De Werd et al. [11]. source comes in line with the four radial apertures. The
One of these inserts for use with an HDR microSelectron variation in response over the first 20 mm from the bot-
is shown in Figure 9.9. The insert consists of a lead cylin- tom of the catheter cavity of the insert (positions 1 to 6)
der 30 mm in diameter, 115 mm long, housed in a 2-mm is within 0.4% and one of these positions may be used
thick brass shield with a 100-mm deep central cavity of for source calibration measurements. When the source is
2-mm diameter, which takes a bronchus source catheter. at position 1, the source center is 6.5 mm from the tip of
The insert has a brass flange through which it is fixed by the catheter: each dwell position corresponds to an
a screw to the top face of the ion chamber. Four 2-mm increment of 2.5 mm. The position of the source can be
diameter holes pass radially through the 15-mm thick programmed to be in the plane of the apertures and the
lead cylinder: the apertures are in a plane at 72 mm from resultant data may then be used as reference information
the base of the insert and intersect centrally at right against which subsequent measurements of source posi-
angles to each other. The collimator insert modifies the tion can be checked.
response of the chamber as the radiation source is This is achieved by a combination of altering the
moved along its longitudinal axis. With the collimator in length of the source cable and/or entering the dwell posi-
place, the response of the chamber increases as the tion of the source. The cable length can be altered in
1 mm increments and the source positions can be
changed in steps of either 2.5 mm or 5 mm: by combin-
ing both of these, it is possible to alter the source posi-
tion in increments of 0.5 mm. This procedure may be
used to move the source step by step across the plane of
the aperture. The resultant profile enables the position of
the aperture to be determined in relation to the pro-
grammed position of the source. The method is useful
for measuring any changes that might occur when
source cables are replaced. Typical profiles are shown in
Figure 9.10: in practice, it is not necessary to record a
complete profile because the location of the maximum
chamber response can be determined satisfactorily by
means of four or five measurements made at 0.5 mm
intervals around the region of the aperture. The method
is very convenient and more precise than autoradiogra-
phy unless densitometric measurements are used: the
method is able to determine a source positional change
Figure 9.8 Frame-grabber image of VariSource source wire of less than 0.5 mm. Comparative measurements using
against a scale at 130 cm travel. (Courtesy of Varian Oncology autoradiography and the well-type chamber insert have
Systems.) shown good correlation.
142 Quality assurance in high dose-rate afterloading

;
igure 9.9 (a) The Standard
waging HDR 1000 re-entrant
?A7 chamber with collimator
nsert. (b) The collimator insert
hawing one of the four
'pertures.

Figure 9.9 shows a PMMA extension scale fixed to the and the relative dwell time accuracy was 5% for a 10 s
collimator insert. This is designed to facilitate with- dwell time.
drawal of the source catheter by a measured distance so
that alternative source positions can be programmed
and checked. For example, if the aperture position is 9.5.2 Positional reproducibility in
found to be at a programmed distance of 54 mm corre- interstitial brachytherapy
sponding to a source position of 18 and a cable length of
919 mm, then by withdrawing the catheter 15 mm the Interstitial and intraluminal brachytherapy with HDR
new aperture position should be at a source position of iridium-192 and PDR iridium-192 afterloading
12 for the same cable length. machines raise special problems in quality assurance.
De Werd et al. [11] have described an alternative qual- Each catheter or needle implanted in the patient is
ity assurance insert which is made of lead and has two attached to the treatment machines via a transfer tube.
acrylic spacers, one of which is 4 mm thick and the other The precise position of the radioactive source is deter-
1 mm thick. The device has been used for checking posi- mined by the programmed length and the dwell position
tional accuracy and also for checking dwell times and selected for a particular treatment. The source position
source activity. As the source is moved across the 1 mm within the needle or catheter is dependent upon the pre-
spacer, the response of the ionization chamber results in cise length of the needle and also upon the length of the
a profile similar to that shown in Figure 9.10, with a full transfer tube. In practice, the lengths of individual nee-
width at half maximum of 13 mm 0.5 mm, with the dles vary, as also do the lengths of individual transfer
peak also falling within 0.5 mm of the same location. tubes. Tube-to-tube variation in length should be no
The authors conclude that the device is very easy to use more than 0.5 mm and similar variations can occur in
and gives more accurate results than conventional radi- the length of individual needles. Various methods of
ographic film, and the measurement of dwell times is checking the length of the needle and tube have been
more precise than measurements made using a stop- described. Williamson [12] has dealt comprehensively
watch. The positional accuracy was found to be 1 mm with some of these issues and has described three
Quality assurance documentation 143

Figure 9.10 Typical


profiles obtained by moving
the HDR microSelectmn
source along the chamber
axis in front of the insert
apertures. Top profile:
345 GBq source; lower
profile: 145 GBq source.

methods for correlating treatment lengths and dwell measuring the distance from the applicator orifice to
position number. These are: the 995 mm seed center of a calibrated radiographic
marker (using graph paper and a transparent
1. The use of a source-like cable with tungsten seed
applicator), the actual transfer tube length may be
markers spaced at 1 mm intervals which is inserted
calculated. Tube-to-tube variations in length should
into the treatment tube applicator and then
be no larger than 0.5 mm.
radiographed. The marker centers function as
3. The applicator tip localization method: this method
individual catheter rulers with 1 cm gradations,
uses the closed end of each applicator to localize the
from which the programmed treatment length can
dummy marker relative to the index frame of
be read. This method has the advantage of
reference in combination with the radiographic
convenience of use, but multiple markers are
marker sounding of each transfer tube applicator
required so that individual markers can be inserted
combination. Simulation markers are fully inserted
into each of the implanted needles (or catheters).
into each implanted catheter and radiographs are
The basic check consists of comparing the marker
obtained: the appropriate transfer tubes are attached
positions of a fully inserted simulation marker with
to the applicators and each transfer-tube-applicator
the position of the actual radioactive source when
assembly is 'sounded' using a calibrated marker to
programmed to dwell at positions corresponding to
obtain the offset variation for each assembly.
the marker seeds. In practice, one marker is used as a
calibration standard against which other markers are In summary, the objectives of any quality assurance
measured: this may be achieved by inserting markers program are to ensure that the length of individual nee-
sequentially into a transparent catheter tube and dles or catheters that are used and also the length of indi-
marking the seed positions on graph paper. The vidual transfer tubes are known. Williamson [12] found,
calibration of the marker consists of superimposing over a 12-month period, the PDR flexible-catheter treat-
a transmission radiograph of the marker upon the ment tube length to be constant within 0.5 mm on
autoradiograph of a source itself. average. Over a 3-year period, semi-flexible HDR trans-
2. The applicator orifice method: this method is based fer tubes maintained their length within 1 mm, with
on the use of the insertion of a dummy marker tube-to-tube length variations within the 0.5 mm range.
relative to the applicator orifice which is constrained
by a small cap on the end of its proximal end. The
simulation marker acts as a 'sound' which is used to
measure the inner length of the needle or catheter,
9.6 QUALITY ASSURANCE DOCUMENTATION
from which the dwell position of the source can be
calculated. The method assumes that all transfer
tubes have the same length and that their average In practice, each user will develop his or her own quality
length is consistent with the cap to distal-node seed assurance program, but certain minimum requirements
position of the marker set. By independently are common to all.
144 Quality assurance in high dose-rate afterloading

The calibration procedure should include details of Electrical interlocks installed at the room entrance
the method used to determine the air kerma strength of should be tested for proper operation. Records of
the source. It is required that calibrations be performed these tests should be maintained for a period of 3
following installation of a new source before patient years.
treatment is resumed and they are recommended at The mechanical integrity of all applicators, source
monthly intervals thereafter. guide tubes, and connectors to be used should be
The following list of quality control checks based on determined by visual inspection and/or radiographs.
NRC recommendations might be considered to be a The presence and correct placement of any internal
minimum requirement: shields and other essential internal components
should be determined.
The afterloading device should be tested to determine The records of all the checks specified above should be
the accuracy of source positioning. Source maintained for a period of 3 years and should include
positioning within the catheter guide tube should be the date of the check, the results of the check, and the
accurate to within 1 mm of the programmed initials of the individual who has performed the check.
position. A record of the test should be maintained
and should include the date of the test, the One important aspect of documentation relating to
programmed position, the actual position of the the use of HDR equipment is that related to the emer-
source following activation of the device, and the gency procedures that need to be implemented should
initials of the individual who performed the test. the source fail to return to its safe position. At a mini-
Ideally, the record should include the radiograph or mum, these procedures should address the following:
autoradiograph used to determine the source The procedures should specify the circumstances in
position. which they are to be implemented, such as any
Timer accuracy and linearity. circumstances under which the source cannot be
For devices that use a cable and/or wire to transport retracted to a fully shielded position in the
the source, measurement of the source guide tube to afterloading device.
confirm the length to 1 mm of accuracy. The action specified for emergency source removal
The back-up battery for the remote afterloading should give primary consideration to minimizing
device should be tested, in accordance with the radiation exposure to the patient and healthcare
manufacturer's instruction, to verify emergency personnel while maximizing safety to the patient.
source retraction capability upon power failure. The The procedures should specify step-by-step actions
minimum requirement for this test should consist of a for equipment failure and specify the individual(s)
function test with the mains power disconnected. responsible for implementing the actions. The
A record of these tests should be maintained for a procedure should clearly specify which steps are to be
period of at least 3 years and should include the date taken in different scenarios (for example, source
of the check, the results of the check, and the initials decoupling versus a jammed source). The procedure
of the individual who performed the check. should specify situations in which surgical
In practice, it is useful to document quality assurance intervention maybe necessary and the steps which
information in the form of a monthly quality assurance must be taken in the event that surgical intervention is
chart (Figure 9.11). required.
The NRC also recommends that at the beginning of In the event of an emergency, the procedures should
each day of use the following checks should be performed specify the names of authorized personnel who
in accordance with the manufacturers' instructions: should be informed, including the Radiation Safety
Officer and/or the Radiation Protection Adviser.
The permanent radiation monitor fitted within the There should be requirements to restrict and 'post' the
treatment room should be checked for proper treatment area with appropriate signs to minimize the
operation. risk of inadvertent exposure of personnel not directly
The television monitor and intercom should be involved in the emergency source recovery.
checked to verify proper operation. It is a requirement that the location of emergency
The treatment console operational functions should source recovery equipment should be specified and
be checked, testing all indicator lamps, other status the equipment that might be necessary for various
and operational displays and, if appropriate, check the equipment failures should be readily available, and
printer and data which it displays. their use described in the emergency procedure. At a
Source status indicators ('safe' or 'unsafe'), including minimum, emergency equipment should include
those which are integral to the afterloading device as shielded storage containers, remote handling tools,
well as any additional indicators installed at the and, if appropriate, supplies necessary to remove
treatment console or room entrance, should be applicators or sources from the patient, including
checked. scissors and cable cutters.
References 145

Figure 9.11 A monthly quality


assurance HDR iridium-192 chart, Royal
Marsden NHS Trust, London, UK. The
Gafchromic autoradiograph is
photocopied onto the chart as a record of
positional accuracy of the source.

REFERENCES Jones, C.H. (1991) Quality assurance using the Selectron-


LDR/MDRand microSelectron-HDR./4rf/V/Yy, 5(4), 12-16.
Veenendaal, The Netherlands, Nucletron BV.
1. ICRP Publication 44 (1985). Protection of the patient in 6. I EC 601 -2-17,1989 (1990) Specifications for Remote-
radiation therapy. Ann. ICRP, 15,2. controlled Automatically Driven Gamma-ray Afterloading
2. Quality Assurance in Radiotherapy (1988) Institute of Equipment. London, British Standards Institute.
Radiation Hygiene and World Health Organisation. 7. The Ionising Radiation Regulations (1999) London,
Geneva, WHO. HMSO.
3. AAPM Report No. 13 (1984) Physical Aspects of Quality 8. Chenery, S.G.A., Pla, M. and Podgorsak, E.B. (1985)
Assurance in Radiation Therapy. American Institute of Physical characteristics of the Selectron high dose rate
Physics for the AAPM. Chapter 6. intracavitary afterloader. Br.J. Radiol., 58,735-740.
4. Ezzel,G.A. (1991) Acceptance testing and quality 9. Speiser, B.L. and Hicks, J.A. (1994) Safety programmes for
assurance for high dose rate afterloading systems. remote afterloading brachytherapy: high dose rate and
Activity, 5(4), 2-6. Veenendaal, The Netherlands, pulsed low dose rate. In Brachytherapy: from Radium to
Nucletron BV. Optimisation, ed. R.F. Mould, J.J. Batterman,
146 Quality assurance in high dose-rate afterloading

A.A. Martinez and B.L. Speiser. Veenendaal.The B.R. (1995) Quality assurance tool for high dose rate
Netherlands, Nucletron International B.V., 270-84. brachytherapy. Med. Phys., 22(4), 435-40.
10. Jones, C.H. (1995) HDR microSelectron quality-assurance 12. Williamson, J.F. (1995) Simulation and source localisation
studies using a well-type ion chamber. Phys. Med. Biol., procedures for pulsed and high dose rate brachytherapy.
40,95-101. Activity Report, 7,57-65. Veenendaal, The Netherlands,
11. De Werd, LA, Jursimic, P., Kitchen, R. and Thomadson, Nucletron-Oldelft.
10
Radiation protection in brachytherapy

A.M.BIDMEAD

10.1 INTRODUCTION policy, based on the appropriate national or state regula-


tions. In the UK, these are the Ionising Radiations
Regulations (IRR) 1999 [7]. These regulations were
A fundamental requirement of radiation protection issued early in 2000 and some aspects of their detailed
when brachytherapy is given is that the patient receiving implementation still need clarification, particularly
treatment, the hospital staff, and the general public are those aspects relating to the protection of the patient.
not irradiated unnecessarily as a result of the brachyther- The previous regulations were IRR 1985 [8], together
apy. Protective measures should therefore be used to keep with the POPUMET Regulations [9], Guidance Notes
the dose levels as low as reasonably achievable (ALARA). [10] and approved codes of practice [11,12]. IRR 1985
Dose limits and recommendations are detailed in the dealt mainly with the safety of employees and the public
Recommendations of the International Commission on at large, whereas the new regulations include issues relat-
Radiological Protection (ICRP), 1977 and 1978, and ing to the protection of patients, previously included in
the International Commission on Radiation Units POPUMET. The hospital policy should describe the
and Measurements (ICRU) and Institute of Physical responsibilities of the hospital, departmental heads,
Scientists in Medicine (IPSM) [1-5]. An extract from radiation protection adviser and supervisors, occupa-
these recommendations, indicating the current and the tional employment medical advisers, and other staff
previous dose limits (Table 10.1) is shown in reference 6. involved with the use of ionizing radiation.
Each hospital in which brachytherapy is carried out is The regulations require all staff concerned with the use
required to have a comprehensive radiation protection of radiation to have adequate training. Radiotherapists

Table 10.1 Dose limits

Effective dose 20 mSv per year averaged 1 mSv in a yearb 50 mSv 5 mSv
over defined periods of
5 years3

Annual equivalent 150mSv 15mSv 150mSv 15 mSv


dose in the lens of
the eye
a
With the further provision that the effective dose should not exceed 50 mSv in any single year.
b
In special circumstances, a higher value of effective dose could be allowed in a single year, provided that the average over 5 years does not exceed
1 mSv per year.
148 Radiation protection in brachytherapy

must have an Administration of Radioactive Substances The following information should be recorded:
Advisory Committee (ARSAC) license to practice
1. the radionuclide, energy, emissions due to decay
brachytherapy, as described in the MARS regulations
2. the source encapsulation
[ 13]. Previously, outside employees - that is, employees of
3. the activity on a given date
another organization or company temporarily working
4. the serial number or other distinguishing mark
in the hospital (e.g., service engineers etc.) -were covered
5. the date of receipt
by the Ionising Radiation (Outside Workers) Regulations
6. the normal location of the source
1993 [ 14], but this aspect is now included in the new reg-
7. the recommended working life of the source (when
ulations. The issues relating to pregnant staff are also cov-
appropriate)
ered in the new regulations. One new aspect in IRR 1999
8. the date and manner of disposal (when appropriate).
is the specific requirement for formal risk assessments to
be performed and documented. Although this was prob- Some sources (e.g., iridium-192) require a storage
ably done previously in a less formal manner, it is now period after initial production to allow the decay of
specifically required. short-lived impurities: the user should ensure that such
There are two main protection issues to address: procedures are followed. Sources (such as cesium needles
and tubes) should be assessed to determine whether they
The design of protected rooms, for the protection of are safe to use or should be replaced.
the patient and staff during treatment and for the
protection of staff preparing and handling sources.
The tracking and recording of the whole treatment 10.2.2 Source integrity checks: leakage
process, starting with the progress of the source from and contamination tests
its protected environment, through to the treatment
delivery, continuing until the source is returned for Before sources are used clinically, and subsequently at
storage or disposal. This ensures a source can be regular intervals, checks should be made to ensure that
traced at every stage [15,16]. they are not leaking and that the distribution of radioac-
tivity within the source is as expected and acceptable for
Radiation protection surveys of the designated rooms clinical use, and that this distribution does not change
and preparation areas, and monitoring of staff radiation with the course of time.
doses provide data on the effectiveness of the radiation Long-lived brachytherapy sources are doubly encap-
protection. sulated for mechanical strength and to prevent leakage of
Protection of the patient includes the prevention of radioactive material in the event of source damage.
gross treatment delivery errors, whether they are as a Sources obtained from manufacturers are issued with
result of device malfunction or of human error in the leakage test certificates, which describe the tests that have
design, evaluation, and execution of the brachytherapy been carried out: these include immersion tests at differ-
procedure. The development and maintenance of a good ent temperatures and wipe tests [18]. For cesium sources
quality assurance program (preferably to a recognized, manufactured in the UK, the safety level is taken to be
auditable standard) are a major factor in effective radia- 200 Bq (5 nCi). It should not be assumed that new
tion protection in brachytherapy. sources are necessarily free from surface contamination.
Long-lived sources in clinical use should be leak tested at
least every 2 years; annual tests should be made on
10.2 QUALITY ASSURANCE ISSUES IN sources that have been in use for several years.
BRACHYTHERAPY PROTECTION New, encapsulated sources should be wiped with a
swab or tissue moistened with water or ethanol and mea-
10.2.1 Source identification and sured using a Geiger-Muller or scintillation counter
description capable of detecting 200 Bq (5 nCi). The method used
should keep radiation exposure to a minimum and it
Sources should be kept safely, with manufacturers' data should swab the outside of the source without causing
sheets or test reports appended to local documentation, abrasions to the source capsule.
so that in the event of loss or damage as much informa- When using iridium (iridium-192) and gold (gold-
tion as possible, relevant to each particular source, is 198) wires and seeds, the principal hazards are those
available [ 17]. The physical and chemical composition of caused by scoring of the surface and particulate frag-
the radioactive source should be noted, including the mentation when the wire is manipulated or cut without
presence of any radioactive impurities. appropriate equipment. Handling tools and cutting
Encapsulated sources with a long half-life should be equipment should be monitored and decontaminated
clearly identifiable and distinguishable from each other. regularly and cutting should only take place under con-
A closed circuit television (CCTV) camera with a close- trolled conditions in protected areas.
up lens is useful for this purpose. In the case of beta-ray sources such as strontium-90/
Source handling and associated protection issues 149

yttrium-90 ophthalmic applicators, special care must pellets (which are used to identify active source positions
be taken because the surface of the applicator is particu- for treatment planning) provides information to cross-
larly delicate. Leak tests must be performed at least reference active sources and dummy source positions.
annually.

10*23 Source strength measurements 103 SOURCE HANDLING AND ASSOCIATED


PROTECTION ISSUES
Before being used clinically, sources should be calibrated
by the user. A useful measurement device is a re-entrant
The steps required for the safe use of radioactive sources
ionization chamber (i.e., an isotope calibrator). In the
from storage, preparation, transportation, insertion,
case of high-activity sources, accurate calibration can
removal, and cleaning are discussed in the following
also be achieved with an ion chamber. The calibration of
paragraphs
both these instruments should be traceable to a national
standards laboratory.
To achieve the required accuracy in the prescribed 103*1 Storage of sealed sources
dose, source calibration accuracy should be better than
5% of the true strength. Most manufacturers are Clean sources should be kept in a locked, radiation-
unable to provide calibrations of this accuracy and the shielded safe designed to allow the safe visualization of
user must carry out independent measurements, but ref- sources and identification marks: the safe should be
erence should always be made to the manufacturer's cal- compartmentalized to permit easy and fast access for
ibration certificate (agreement within 10%). removing individual sources and for carrying out stock
checks. The safe should be situated close to the source
preparation bench for easy access. The storage safe or
10*2.4 Autoradiography and radiography
container should be swab tested annually and any
radioactive contamination found should be removed
These techniques can be used together or separately to
and its source of origin identified.
provide information about the distribution of radioac-
A detailed inventory of the number, type, and activity
tive material within the container and positional infor-
of sources in the store must be kept in addition to details
mation about individual sealed sources in radioactive
of sources being used in patients. When there is a large
source trains.
number of long-lived sources, it is helpful to use a dis-
Autoradiography is useful for checking the uniformity
play board or computer spreadsheet to track and record
of wire sources and ribbons or radioactive seeds and pel-
the whereabouts of each individual source.
lets. When radioactive wires are cut, it provides a means
An audit should be carried out at regular intervals for
of recording particulate contamination. Needle sources
every source in storage or in use. In the UK, an indepen-
might have two or more cells: the source activity and dis-
dent audit should be made annually by a senior person
tribution in each cell can be checked with this method.
nominated by the employer.
Autoradiography and radiography should be used to
Lead carrying pots should be monitored after transfer
check the configuration of single and multiple sources in
of sources to ensure that all sources have been removed.
preloaded source trains. In the case of afterloading
To reduce the chances of source loss, it is useful to have
machines whose source configuration can be pro-
gamma-ray alarms at the exits to areas where sealed
grammed, autoradiographic checks should be carried
sources are routinely used.
out at commissioning and after machine service or
source or catheter replacement to ascertain the precise
location of each source and the integrity of software and 103.2 Preparation of sources and
machine function. applicators for clinical use
Applicators into which sources are loaded, either by
hand or automatically by machine, should be checked by Radioactive sources should not be issued or used clini-
autoradiography before being put into clinical use, and cally without a written request from an authorized per-
thereafter annually. Moulded wax is useful for position- son: transfer of the source(s) should be recorded, and
ing and supporting the applicators. Lead-foil markers responsibility for the source taken by different signato-
embedded into the surface of the wax can be used to pro- ries during each stage of the source transfer, implant, and
vide identification marks and scales which are imaged on source return.
film by electron emission. The method allows precise Manipulation of sources should be with long, low-
comparisons to be made of different applicators and pressure forceps to avoid mechanical damage; the for-
provides a radiographic record of the location of the ceps should be monitored and cleaned after use. Wire
radioactive sources inside loaded applicators. Radio- sources should be cut only with an appropriately
graphy of the same applicators containing dummy designed cutter. Wire sources with cut ends should be
150 Radiation protection in brachytherapy

sealed in plastic tubing before being inserted into body


tissues. The tools used to prepare wire sources (cutters
etc.) should be labelled and used only for this purpose,
checked for contamination at least twice a year, and kept
sharp. All handling must be carried out behind protec-
tive barriers which reduce the radiation to the abdomen
and chest. A protected observation screen is also useful
to reduce the dose to the head and eyes. The speed and
skill of the operator are also important. It is good prac-
tice to limit the number of sources out of the protected
storage area at any one time.
When necessary, sources should be sterilized before
clinical use. The efficacy of the process must be checked.
The source manufacturer should be consulted about the
effect of sterilization on source integrity: the sterilization
process must not be detrimental to the containment of
the radioactive source. Sources such as cesium needles
and tubes should not be exposed to temperatures above
180C. Iridium-192 is baked 'dry' at 150C for 1 hour.
Some brachytherapy techniques make use of empty
applicators, needles, or catheters into which the sources
are after-loaded. These devices should be checked before
and after use to ensure that they are mechanically sound
and free of contamination.
Figure 10.2 Long-handled carrying pot.

1033 Transportation of sources

Sources are carried from the preparation bench to the 10.3.4 Insertion of sources into patients
patient in a specially designed lead pot. For iridium-192
wire, preloaded in plastic tubes, the pot is designed to be Mobile protective lead shielding barriers are used wher-
sufficiently protective whilst not being too heavy to carry ever practicable around the patient's bed. Optimal thick-
(Figure 10.1). Alternatively, iridium hairpins and cesium ness is 2-2.5 cm lead, which reduces the dose recorded
sources can be transported in a long-handled, lead-lined on film monitors worn at waist level to 50% of the dose
pot which uses the principles of distance in addition to recorded when worn on the chest. Faulkner et al. [19]
protective material to provide a reduction in radiation recommend wearing monitors at chest level when lead
dose (Figure 10.2). Associated documentation accompa- shields are used, but at abdominal level when remote
nies the sources. after-loading systems are universally used. Using long-

Figure 10.1 Iridium wire-carrying pot.


Source handling and associated protection issues 151

handled forceps, the physicist and radiotherapist load time indicated each day would, after 5 consecutive days,
the active sources into the patient as quickly as possible, have received a dose equal to his or her average weekly
fixing each source in place as it is positioned. The func- dose limit.
tion of the radiation detector in the treatment room is The nurse in charge of the ward is responsible for
checked and warning notices posted outside the pro- ensuring that the time on the warning notice is set cor-
tected room for the duration of treatment (in addition to rectly each day in accordance with Table 10.2 and for
illuminated signs warning of radiation dose in con- removing the notice on the day indicated.
trolled areas). A lead pot and long-handled forceps are While the brachytherapy treatment is taking place, the
left in the room with the patient in case of emergencies. protected room becomes a controlled area and staff enter
If the patient is moved at any time from the protected under local rules only. Emergency procedures (e.g.,
room (such as for X-ray), a radiation warning notice unplanned removal of source, patient bleed) are docu-
should be prominently displayed on the trolley or chair mented in the local rules and are dependent on the site
in which they are transported. and activity of implant. Visitors are discouraged, but if
The use of small sealed sources, such as iodine-125 absolutely necessary are allowed to spend no more than
seeds, has great protection advantages (provided that the the daily 'nursing time' with the patient.
sources are not lost), as shown by Hilaris et al. [20,21].
Exposures of the order of 2 |LlSv h"1 per 37 MBq at 0.75 m
103*6 Removal of sources from patients
from a patient with a prostate implant have been mea-
sured by Liu and Edwards [22]. The greater protection
When sources have to be removed from a patient, either
hazard occurs if all sources cannot be accounted for. It is
at the end of treatment or, occasionally, if a source has
good policy to X-ray patients as soon as possible after
been inadvertently displaced, they should be removed
implantation and to keep good account of the total
carefully to avoid patient trauma and source damage.
number of sources used.
Sources should be placed in a lockable, shielded con-
tainer lined with a plastic pot containing bactericidal
103.5 Treatment delivery fluid. When removing iridium wire sources contained in
plastic tubes, great care must be taken not to cut the wire
The time that the sources were inserted into the patient when removing the sources. The patient must be
and the proposed removal time (dependent on dosime- checked with a Geiger-Miiller monitor after removal of
try calculations)) are recorded. The nurse in charge of sources from the treatment room to confirm that all
the patient accepts responsibility for the custody of the radioactivity has been removed from the patient.
radioactive sources whilst they are in the patient and The sources should be returned to the laboratory/
ward by signing the appropriate paperwork. The time store as soon as possible after removal from the patient,
that the nurse may spend with the patient (daily nursing where they should be counted, checked for damage, and
time) is calculated from Table 10.2 (used for iridium stock records completed. Responsibility for the sources is
implants) and is dependent on the total activity transferred from the ward nurse to the person who
implanted. Permissible times, indicated by radiation transfers the sources and then to the source curator. Only
warning notices, are intended as a guide to nursing staff. after all sources have been accounted for should the
Nursing procedures can safely be carried out, but unnec- patient be allowed to leave hospital.
essary time must not be spent close to the patient while
the warning notice is displayed.
103*7 Source and applicator cleaning
The times given in Table 10.2 are such that a nurse
remaining at a distance of 50 cm from the patient for the
It is necessary to clean sources that have come into con-
tact with body tissues before they can be stored and/or
Table 10.2 Times for different total activities of iridium re-used. Immersion in bactericidal fluid on removal
administered from the patient prevents biologically active material
reaching the laboratory store. Source manufacturers
should advise about cleaning procedures: damage to
0.3-0.6 GBq (300-600 MBq) 1h source capsules can occur as a result of chemical attack if
0.6-1.3 GBq (600-1300 MBq) 30min inappropriate cleaning agents are used.
1.3-2.5 GBq (1300-2500 MBq) 15min Wire sources that are to be re-used should be
2.5-3.8 GBq 10min inspected for damage and re-measured prior to use.
3.8-6.5 GBq 5min After removal from the patient, applicators (catheters
6.5-13 GBq 3 min etc.) should be immersed in bactericidal fluid, cleaned,
13-20 GBq 1 min and inspected for damage.
In these cases the time to be indicated remains the same for each day Radioactive sources are often inserted into patients in
the radioactive sources are in position. sealed plastic tubing, plastic applicators or stainless-steel
152 Radiation protection in brachytherapy

tubes. It is good practice to check these source-carrying that treatment times can be reduced (low-medium dose
devices for radioactivity with a Geiger-Miiller monitor rate treatments). Patients can be treated as out-patients
after each use. for fractionated high dose rate treatments (with cesium-
137 and iridium-192).

10.4 AFTERLOADING 10*4.2 Manual afterloading

Radiation exposure can occur during:


10.4.1 General
transfer of source from storage and preparation for
Afterloading in brachytherapy has achieved the biggest use
improvement in radiation protection of staff and, transfer from preparation bench to patient
indeed, also of patients. It has minimized the exposure to irradiation of patient
the technical staff involved in the preparation and trans- removal of sources from patient and transfer to
portation of sources and it has reduced the dose to med- storage
ical staff. Staff on the wards who nurse patients have removal from applicators, cleaning, returning to
their doses reduced by the use of automatic afterloading. storage.
During afterloading techniques, applicators or
catheters are inserted into a patient and subsequently
10.4.3 Remote afterloading
loaded with radioactive sources. This method allows
optimal positioning of the applicators (or catheters)
Radiation exposure can occur when:
without any radiation exposure to the clinician or sup-
port staff. Afterloading of the radioactive sources can machine/door interlocks do not function
either be achieved by hand or remotely with specially sources are changed
designed equipment that drives one or more of the sources stick.
sources into the patient. In both situations, afterloading
Regular quality assurance of the remote afterloading
occurs after the patient has had localizing radiographs
machine helps to prevent machine malfunction and
and, in the case of conventional brachytherapy, has
unnecessary radiation exposure.
returned to the ward or room where treatment is to be
delivered. Although manual afterloading largely elimi-
nates exposure of the clinician, some staff have sti