Brachytherapy, Radionuclide Therapy Medical...
Transcript of Brachytherapy, Radionuclide Therapy Medical...
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Brachytherapy, Radionuclide Therapy
Medical Physics in the Clinic
Raymond K. Wu, PhD
Chairman
AAPM Exchange Scientist Program
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TG 43 of 1995
New dose calculation formalism for
brachytherapy
Consensus data for Pd-103 and I-125
seeds
Resolution of the 17% discrepancy for
some seed types
Significant improvements in dosimetry
methodologies
Med. Phys. 22 (2), February 1995 pp.209-234
AAPM Exchange Scientist Program – Wuhan China 2015
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After TG 43
Source Activity or Apparent Activity => Source Strength (unit is U
or cGy per hour at 1 cm) Sk
Milligram Radium Equivalent => U
Exposure Rate Constant => Dose Rate Constant Λ
Tissue Attenuation Coefficient => Tabulated data
Ignoring source construction and design => Radial Dose
Function, Anisotropy Factor, Anisotropy Function Table Clinical work not standardized for source design except as a point
source => Standardized for radioactive sources of various
size, shape, and construction
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TG 43 U1 - 2004
Revised definition of Air Kerma Strength
Elimination of Apparent Activity as source
strength
Elimination of Anisotropy Constant and
replaced by Anisotropy Functions 1D and
2D
Other minor improvements
Med. Phys. 31 „3…, March 2004, pp.633-674
AAPM Exchange Scientist Program – Wuhan China 2015
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SK is Source Strength in U
Λ is Dose Rate Constant
gL(r) is Radial dose function
F(r,θ) is Anisotropy function
r0 is 1 cm, and θ0 is 90°
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ρ(r’) is density of radioactivity at r’
r’ is (x’, y’, z’) within the integrated volume V
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It may be shown for a point source, the TG 43
equation becomes
F(r,θ) may be simplified as a function of r,
which becomes the Anisotropy factor Φan(r)
AAPM Exchange Scientist Program – Wuhan China 2015
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Example for
Cs 131 (IsoRay Medical)®
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Cs 131 (IsoRay Medical)®
Dose Rate Constant (cGy/h-U) 1.06
Anisotropy Constant 0.964
Half Life (days) 9.689
Active Length (cm) 0.40
Physical Length (cm) 0.45
Physical Diameter (cm) 0.08
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Cs 131 (IsoRay Medical)®
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Cs 131 (IsoRay Medical)®
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Point source approximation
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Cs 131 (IsoRay Medical)®
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Line source
approximation
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Cs 131 (IsoRay Medical)®
AAPM Exchange Scientist Program – Wuhan China 2015
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Prostate Seed implants
I-125 seeds
Pd-103 seeds
LDR Implants
Ir-192 ribbons
Cs-137 sources
HDR Sources
Ir-192
Co-60
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Common Radionuclides in Rad Onc
Symbol Primary Emission
Energy (or max energy) keV
Half-life 10 half-lives
60Co gamma 1170-1330 5.26yrs 53 yrs
89Sr beta Ave 1.463 MeV 50.5 days 1.4 yrs
90Sr beta/gamma 546 (up to 2.27 MeV) 28.5 yrs 285 yrs
103Pd gamma 21 17 days 170 days
125I gamma 27-36 60.2 days 20 months
131I gamma 364, 637 8.04 days 2.7 months
131Cs beta/gamma EC 29 9.7 days 3.25 months
137Cs gamma 510, 1180, 662 30 yrs 300 yrs
192Ir gamma/beta 380 73.83 days 2 yrs
223Ra alpha 5.78 MeV 11.43 days 114 days
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Radionuclide Therapy
I 131 Thyroid Ablation
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I-131 Thyroid Ablation
Limit of Removable
contamination
< 2000 dpm/100cm2
•Washable chair covers
•Disposable absorbing
padding material
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• Liquid form of I-131
• In house radiopharmacist
• Urine storage for decay
• Decontamination tasks
• Fume hood
• Bioassays
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Inhaled or Ingested
Radioactive Material
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ACPSEM Summer School 2014 – Melbourne
Committed dose equivalent (HT,50)
The dose equivalent to organs or
tissues of reference (T) that will be
received from an intake of radioactive
material by an individual during the 50-
year period following the intake.
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Committed effective dose equivalent
(HE,50)
The sum of the products of the weighting
factors applicable to each of the body organs
or tissues that are irradiated and the
committed dose equivalent to these organs
or tissues
HE,50 = ΣWTHT.50
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Historical dose information for
Radiation Oncology staff
Radiation Oncology staff 2011
maximum 2-month whole body dose was 0.08 mSv
maximum whole body yearly total was 0.08 mSv
maximum annual extremity exposure was 0.17 mSv
Radiation Oncology staff 2012
maximum 2-month whole body dose was 0.041 mSv
maximum whole body yearly total was 0.041 mSv
maximum annual extremity exposure was 0.070 mSv
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Other Radiation Oncology Procedures
Cyberknife X-sight Lung, X-sight Spine
Image Guided RT
Cs-131 brain implant
Prostate seed implant
LDR cervix endometrium implants
Zevalin, SIR sphere procedures
Xofigo, Metastron procedures
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AAPM Exchange Scientist Program – Wuhan China 2015
Let us focus on HDR
High Doserate
Remote Afterloader
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HDR
High Doserate
Remote-afterloader
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Nucletron Microselectron – Version 2
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One single source
4 mm long
Iridium – 192
Emits 350 kV ɤ ray
Half Life 73.8 days
Max activity allowed – 10 Ci
Source replacement 3-4 time per year
When activity becomes 3-4 Ci
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Popular because
• Drastically reduces exposure to staff
• Can reduce unnecessary dose to patient
• Can minimize risk of source inadvertently
left in patient
• Can produce desirable dose distribution
• Greatly increases throughput-Outpatient
• Allows for adjustment of applicators
• Computerized documentation
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The Devil is in the
Applicators
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MammoSite
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Contura
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Tandem & Ovoid
CT/MR Applicator
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Esophageal
Applicator
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Multi-purpose
Applicator
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Source Location Simulator
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Misadministration USNRC
Delivering treatment to the wrong patient
Using the wrong radioisotope
Treating the wrong site
Using leaking sources
Failing to remove a temporary implant
Delivering a radiation dose differing more than
20% from the prescribed dose
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Risks
Very High dose rate affords little time to correct
problem
Intrinsically complicated system takes longer to
learn
Radiation biology different from external beam
Sharp dose gradient requires better anatomical
data
High risk to staff if failure of unit occurs
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PermaDoc by Mick
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Transfer Tubes
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AAPM Exchange Scientist Program – Wuhan China 2015
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AAPM Exchange Scientist Program – Wuhan China 2015
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AAPM Exchange Scientist Program – Wuhan China 2015
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AAPM Exchange Scientist Program – Wuhan China 2015
Rotte Applicator -
Radiochromic film
exposed by HDR
source and by 6e
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Dummy Sources
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AAPM Exchange Scientist Program – Wuhan China 2015
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AAPM Exchange Scientist Program – Wuhan China 2015
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AAPM Exchange Scientist Program – Wuhan China 2015
Global Threat
Reduction Initiative
GTRI
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Security of Radioactive
Material – GTRI program
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Security of Radioactive Material – GTRI program
AAPM Exchange Scientist Program – Wuhan China 2015
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Men and women are
created to take care
of the necessity AAPM Exchange Scientist Program – Wuhan China 2015
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When necessary we
may apply the law
inconsistently AAPM Exchange Scientist Program – Wuhan China 2015
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We may overkill if we
just want to deliver
AAPM Exchange Scientist Program – Wuhan China 2015
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Pay proper attention
No need to be afraid
AAPM Exchange Scientist Program – Wuhan China 2015
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BEIR VII
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AAPM Exchange Scientist Program – Wuhan China 2015
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NCRP 116 Public Dose Limits
0.25 mSv/yr per site
Annual background radiation doses in
USA 4.1 mSv / yr
1 mSv
Cosmic background (5%)
0.34 mSv
Indoor Radon
(37%) 2.45 mSv
Radiography/fluoroscopy
(5%) 0.35 mSv
Interventional fluoroscopy (7%) 0.47 mSv
Nuclear Medicine
(12%) 0.8 mSv
CT (24%)
1.6 mSv
Internal (5%) 0.33
Terrestrial (3%) 0.2mSv
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0
0.1 mSv
0.06
Extremity x-ray
Trans-continental
flight
Chest x-ray
0.02
0.04
1-week dose in
US, all sources
Annual dose
from building
materials
Transpolar
flight
0
1 mSv
0.6
0.2
0.4
0.8
0
10 mSv
6
2
4
8
Radiation Doses in Perspective
Annual
terrestrial dose
in Maryland
Annual cosmic
rays
Internal to body
Annual dose from
medical exams
Annual
terrestrial dose
in Denver
BSS annual
limit to public
US Annual
dose from
natural
background
Apollo XVI
astronauts
Modern
CAT scan
0.08
Annual dose
natural bkgd:
Kerala 15 mSv
Denver 6 mSv
AAPM Exchange Scientist Program – Wuhan China 2015
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As Low as Reasonably
Achievable (ALARA)
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Radiation Hormesis
Case of a Taiwan high rise apartment built with
contaminated reinforcement steel, published in 2007
• 1700 apartment units, 10,000 occupied building
• 40 mSv average dose received
• Cancer death only 3% of natural incidence
• Congenital malformation only 7% of general public
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IOMP Policy Statement No. 3 http://www.iomp.org/?q=node/5
This policy statement addresses predictions of
induced cancers and cancer deaths in a
population of patients exposed to low doses
(<100 mSv) of ionizing radiation during medical
imaging procedures.
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Prospective estimates of cancers and cancer deaths induced
by medical radiation should include a statement that the
estimates are highly speculative because of various random
and systematic uncertainties embedded in them. These
uncertainties include dosimetric uncertainties; epidemiological
and methodological uncertainties; uncertainties from low
statistical power and precision in epidemiology studies of
radiation risk; uncertainties in modeling radiation risk data;
generalization of risk estimates across different populations;
and reliance of epidemiological studies on observational
rather than experimental data. Such uncertainties cause
predictions of radiation-induced cancers and cancer deaths to
be susceptible to biases and confounding influences that are
unidentifiable.
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IOMP Policy Statement No. 3 http://www.iomp.org/?q=node/5
Paragraph A86 of Report 103 of the International
Commission on Radiological Protection (ICRP)
states that “There is, however, general
agreement that epidemiological methods used
for the estimation of cancer risk do not have the
power to directly reveal cancer risks in the dose
range up to around 100 mSv”.
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IOMP Policy Statement No. 3 http://www.iomp.org/?q=node/5
Further, UNSCEAR Report A-67-46, approved in
May, 2012, states that “The United Nations
Scientific Committee on the Effects of Atomic
Radiation (UNSCEAR) does not recommend
multiplying very low doses by large numbers of
individuals to estimate numbers of radiation-
induced health effects within a population
exposed to incremental doses at levels
equivalent to or lower than natural background
levels.”
AAPM Exchange Scientist Program – Wuhan China 2015
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IOMP Policy Statement No. 3
Paragraph 151 of ICRP Report 103 states: “The
use of effective dose for assessing the exposure
of patients has severe limitations that must be
considered when quantifying medical exposure”,
and “The assessment and interpretation of
effective dose from medical exposure of patients
is very problematic when organs and tissues
receive only partial exposure or a very
heterogeneous exposure which is the case
especially with x-ray diagnostics.”
AAPM Exchange Scientist Program – Wuhan China 2015
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IOMP Policy Statement No. 3 http://www.iomp.org/?q=node/5
Predictions of radiation-induced cancers and
cancer deaths from medical imaging procedures
should be accompanied by estimates of
reductions in patient morbidity, mortality and cost
resulting from the same medical imaging
procedures
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ACPSEM Summer School 2014 – Melbourne
IOMP Policy Statement No. 3 http://www.iomp.org/?q=node/5
If effective dose is used to generate predictions
of cancers and cancer deaths, a statement
should be included that the ICRP has expressed
caution in the use of effective dose for purposes
of estimating risks to individuals or populations
exposed to ionizing radiation.
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AAPM Exchange Scientist Program – Wuhan China 2015