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Transcript of brachytherapy
Lecture 21Lecture 21 Ahmed GroupAhmed Group
General Lecture in
BRACHYTHERAPY
Outline
Introduction
Technical
Dose calculations
Clinical
Introduction
Brachytherapy -is the internal radiation treatment achieved by implanting radioactive
material directly into the tumor or very close to it .
Sometimes called internal radiation therapy.
Prefix “brachy” – from Greek for “short range” Greek “brachys” meaning short, contrast to “tele”
meaning distant (teletherapy)
Can be interstitial, intracavitary or surface
High local radiation dose with fast dose fall off
History
Discovered in 1898, radium was most common brachytherapy source
Not used today due to high -ray energy (shielding problems)
Chemical and radioactive toxicity of radium and byproducts
Typical artificial, -ray emitting isotopes used e.g. cesium, iridium, gold, iodine
History
X-rays discovered before radium – radium used for treatment first
Alexander Graham Bell 1903Suggests encapsulation in needles for direct
insertion into cancer lesions
Advantages
Usually out-patient no hospitalization
Highly conformal dose distribution and good healthy tissue sparing
Since source is implanted less concern for localization and target motion
Very high local doses
Advantages
• Usually out-patient no hospitalization
• Highly conformal dose distribution and good healthy tissue sparing
• Since source is implanted less concern for localization and target motion
• Very high local doses
Types of Brachytherapy
• Intracavitary implant, in which sources are placed into body cavities close to the tumour volume.
• Interstitial implant, in which sources are implanted surgically within the tumour volume.
• Surface (mould) implant, in which sources are placed over the tissue to be treated.
• Intraluminal implant, in which sources are placed in a lumen.
• Intraoperative implant, in which sources are implanted into the target tissue during surgery.
• Intravascular implant, in which a single source is placed into small or large arteries.
Types of Brachytherapy
Interstitial• Surgical placement of sources within the tissue
• Temporary or permanent
• Most common application for permanent implant of prostate cancer
• Other sites include: some gynecological tumours, breast tumours and head and neck
Lecture 21Lecture 21 Ahmed GroupAhmed Group
Interstitial Brachytherapy
Interstitial brachytherapy can be either temporary or permanent.
Temporary brachytherapy.
Most widely used radionuclide at the present time is iridium-192
Lecture 21Lecture 21 Ahmed GroupAhmed Group
Temporary Brachytherapy.
The relatively short half-life of iridium-192 (70 days) means that a range of dose rates is inevitable. It is important, therefore, to correct the total dose rate.
Iridium-192 has two advantages:
1) The source size can be small, and2) Its lower photon energy makes radiation
protection easier than with radium or cesium-137
Lecture 21Lecture 21 Ahmed GroupAhmed Group
Temporary Brachytherapy.
Sources of thisradionuclide are ideal for use with computer-controlled remote afterloadersintroduced in 1990s.
Lecture 21Lecture 21 Ahmed GroupAhmed Group
Lecture 21Lecture 21 Ahmed GroupAhmed Group
Permanent Interstitial Implants
Encapsulated sources with relatively short half-life can beleft in place permanently. There are two advantages for thepatient:
1) An operation to remove the implant is not needed,2) the patient can go home with the implant in place.
Iodine-125 has been used most widely to date for permanentimplants.The total prescribed dose is usually about 160 Gy at the peripheryof the implanted volume, with 80 Gy delivered in the firsthalf-life of 60 days.A major advantage of iodine-125 is the low energy of the photonsemitted (about 30 keV).
Lecture 21Lecture 21 Ahmed GroupAhmed Group
Permanent Interstitial Implants
A number of other new radionuclides are under considerationas sources for brachytherapy that share with iodine-125 theproperties of a relatively short half-life and low-energy photonemission to reduce problems of radiation protection.
Types of Brachytherapy Intracavitary
• Sources placed within body cavity via special applicator
• Intracavitary treatments are always temporary
• Most common implant worldwide
• Most gynecological tumours of the uterine cavity and vagina
• Intraluminal: sources through lumen of vessel; e.g. bronchus, esophagus or bile duct
Types of Brachytherapy
Surface Molds• Radioactive sources placed in specially
designed surface molds
• Molds placed on surface of target to treat superficial tissue
• Less commonly used
Loading systems
Manual hot loading• Initial technique with sources placed by staff directly
into patient, high dose to staff
Manual Afterloading• Needles, catheters, or applicators inserted into tumour
• Confirm position, then load radioactive seeds by hand
Remote Afterloading• As above, but seeds are loaded remotely under
computer control to minimize dose to staff
Duration of treatmentPermanent implants
• Many radioactive sources implanted and left to decay within patient
• Distribution of sources cannot change after implant
• Isotopes with low energy (tens of keV) and short half lives (~days)
• 125I, 198Au and 103Pd
Duration of treatment
Temporary implants• Radioactive source placed near treatment site for short
time period (up to 20 minutes) then removed when desired dose is delivered
• Better control of dose distribution
• Usually fractionated
• Can alter insertion in subsequent fractions
Dose RatesLow dose rate: LDR (0.4 to 2.0 Gy/hour)
• Permanent, manual afterloading techniques• Temporary treatments over days requiring hospitalization• Most common historically
Medium dose rate (2 to 12 Gy/hour)• Rarely used, pulsed dose rate (high dose rate exposed for
5 – 10 min / hour) ~LDRHigh dose rate: HDR (>12 Gy/hour)
• High activity 10 CI 192Ir source, remote afterloading• Out-patient treatment, time ~ minutes• Requires increased radiation shielding • Renewed interest in brachytherapy
Technical
Sources
Brachytherapy sources are usually encapsulated; the capsule serves several purposes:
Containing the radioactivity;
Providing source rigidity;
Absorbing any and, for photon emitting sources, radiation produced through the source decay.
SourcesAlthough 226Ra was original brachytherapy source –
not idealCharacteristics
• Energy of -ray (shielding)• Half life• Toxicity• Machinability• Specific activity• Source strength;• Inverse square fall-off of dose with distance from the
source
Brachytherapy sources
Isotope <Energy> (keV) HVL (mmPb) Production T1/2 (Rcm2mCi-1hr-1) Activity DecayPd-103 21 0.008 neutron 17d 1.5 5 mCi EC, I-125 28 0.025 neutron 60d 1.5 0.5 mCi EC, Ir-192 360 2.5 neutron 74d 4.7 10 Ci Cs-137 662 5 fission 30y 3.3 20 mCi Ra-226 1030 8 natural 1600y 8.25 Co-60 1250 12 neutron 5.25y 13 5-10 kCi
192Iridium
Complicated -ray spectrum with average energy ~ 360 keV
Moderate -ray energy requires less shielding than some isotopes
Short half life means sources replaced routinely (3 months)
High specific activity allows for small source size (0.6 x 5 mm) with high activity (10 Ci)
Brachytherapy sources(a) active length, the
distance between the ends of the radioactive material; (b) physical length, the distance between the actual ends of the source; (c) activity or strength of source, (mg radium content); and
(d) filtration, transverse thickness of the capsule wall, (mm Pt)
Varian (VariSource)
0.6 diameter, 5mm long iridium seed welded to Nitinol (Ni/Ti) flexible wire
Wire mechanically drive out of afterloader through one of 20 channels
Program range of treatment positions and dwell times
Typically 0.5 cm step sizes (up to 20 steps)
Stepping of source
150 cm147 cm
to machine
OperationSource stored within unit in shielded safeReceives command to send out sourceSends out ‘dummy’ wire to check path clearStepper motor drives active wire out to
most distal desired position of 1st channelRetracts wire in planned steps and dwells at
each position for required timeRetract source completed and repeat in
other channels if required
VariSource Afterloader
Calibration of Brachytherapy Sources
Specification of Source Strength • Activity
– Number of dis/s (1 Ci = 3.7 1010 dps) • Exposure rate (ER) at a specified distance
– NCRP recommendation, usually at 1 m • Equivalent mass of radium
– Divide ER by the ER constant for Radium • Apparent activity
– Bare point source (no filtering) • Air kerma strength
– AAPM recommendation
Historically source strength specified by exposure, X [R]
Currently source strength specified by air kerma strength (SK)
Relating the two SK = X(R/h) (W/e)
= X(R/h) (8.76 x 103 m2 mGy/R)• (W/e) average energy absorbed per unit charge
of ionization in air (0.876 cGy/R)
Exposure Rate Calibration
Exposure is being phase-out and Air kerma is replacing it.
• Open air measurements
– Hard to measure output, used to calibrate sources
• Well-type ionization chambers
– Calibrated against a calibrated source
– More suitable for routine work
Exposure rate calibrationNIST calibrates in air at 1m with spherical graphite
chamber
Used to calibrate well type ionization chamber
These are used for routine calibration
Recalibrated every two years at accredited dose lab
Specific to isotope of interest
Activity calibration
Well-type chamber to measure activity and compare to manufacturer specifications
Correct for temperature and pressurePerform measurements at chamber “sweet
spot” – highest dose responseagree to within 0.5%
Well-type ion chamber
Dose Calculations
Dose is determined by three factors
(a) Inverse square law ( (
(b) Attenuation in tissue
(c) Scatter in tissue
(1) Point Source:
1/r2
)e-r(
Ď(P) = A Γ (1/r2) (e-r) Ks
Task Group -43 Modular method of dose calculation using tabular
data as a function of position
)(),()2/,1(
),(),( rgrF
G
rGSrD Krate
SK = air kerma strength [U = cGy cm2 h-1]
= dose rate constant (type of source, its construction and encapsulation), dose rate per unit SK at 1 cm along the transverse axis of source; =Doserate(1,/2)/SK
G(r, ) = geometry factor (accounts for falloff of photon fluence from source; 1/r2 for a point source
F(r, ) = anisotropy factor normalized to =/2
g(r) = radial dose function; radial dependence of scatter and absorption in the medium along transverse axis
TG - 43
For 192Ir, anisotropy less significantSimplify by assuming point source= 1.11 cGy h-1 U-1
g(r) available in tabular form
2
)(11.1),(
r
rgSrD K
Source LocalizationOrthogonal Imaging
Applicator positions digitized on each filmy coordinate common to bothApplicator position stored as x, y, z and
corrected for magnification using known length or geometry
Can also be done at smaller angles (stereo shift method ± 20°), larger errors
Difficulties: mag factor, many coplanar seeds and patient motion
Source LocalizationOrthogonal Imaging
Orthogonal Images
PA image LAT image
Tip of marker seed #7 in catheter #2
Source LocalizationCT Imaging
More complex implants require CT imagingProstate uses up to 20 lines insertedImplant applicators, CT image of areaDigitize applicator locations in 3DDigitize organs at risk and define tumour
volume to be treatedBetter visualization of anatomyIncreased time and transport patient to CT
Source LocalizationUltrasound Imaging
Trans-rectal ultrasound allows for visualization prostate, urethra, bladder etc
Planning ultrasound allows for generation of pre-plan
Planned needle positions referenced to grid template sutured to patient’s skin
Implant done under GA with ultrasound guidance; monitor needle placement
Clinical sites
Clinical sitesSiteTypeDose
rate
Dose/#fx
)cGy(
Imaging
EndometriumIntracavitaryHDR*1800 / 3X-ray
CervixIntracavitaryHDR*2500 / 5
2600 / 4
X-ray / CT
ProstateInterstitialHDR2100 / 3CT
InterstitialLDR (125I)
14 400US
EsophagusIntralumenalHDR1800 / 3X-ray
LungIntralumenalHDR2100 / 3X-ray
*previously LDR Cs-137
Carcinoma of the endometrium~3600 cases / year (Canada); JCC 100Standard treatment hysterectomy - curativeTreatment to dome of vagina recurrenceCombined with external beam radiationTarget vaginal mucosal lining Prescribe dose to surface of cylinderSimple application, no sedation requiredDiameter conform to patient anatomy
Vaginal treatments
Cervical cancer~ 1400 cases / year; JCC 200 Combined with external beam radiation and
chemo as curative treatmentTarget vaginal fornices, cervix and
endometriumPrescribe dose to point ATolerance dose uterine vessels cross ureterTandem length variable Sedation required, sterile procedure
Uterine Cervix
Uterine Cervix
Seed #7 cervical os
PA image LAT image
Rectal retractor
Uterine Cervix
Foley catheter
Dose to bladder and rectum
Lung cancerSurgery, external beam, chemo and brachyBrachytherapy palliative treatment onlyObstructive lung tumours – open airwayPrescribe dose 1 cm radial to catheter or to
volumePlace catheter(s) with bronchooscope under
conscious sedation Treat multiple obstructions if necessary
Prostate cancer~18000 cases/yearTreat with surgery, ext. radiation, brachyBrachy limited to early stage (I and II)
disease confined to prostateHDR implants and LDR permanent
implants usedBoth require high dose to prostate volume
and sparing of urethra and rectum
HDR procedureNeedles and catheters inserted into prostate with
template under US guidanceCT of volume; contouring of prostate and organs
at riskTreatment plan created and treatment deliveredCatheters can be removed and reinserted for
subsequent fractions, orCatheters remain in place and treatment repeated
later (Day 1: CT am treat pm; Day 2: treat am and pm
Dose to prostate ~2000 cGy (2x10 or 3x7)
Misc. SitesInterstitial brachytherapy can be performed
nearly anywhere•Breast tumours•Brain tumours•Head and neck tumours•Gynecological implants
Intravascular brachytherapy (restenosis)
Bile duct
Nasopharynx
Partial Breast Treatment