ICRU Recommended Dose and Volume Specification for Reporting Interstitial Brachytherapy

Ali S. Meigooni, Ph.D.

University of Kentucky Medical Center, Department of Radiation Medicine Lexington, KY

Table of Contents

Introduction Definitions of Terms and Concepts

Temporary and Permanent Implants Source Specification Description of Source Patterns Total Reference Air Kerma Volume and Planes Description of Dose Distribution Time Dose Factors

Definition of Quantities
Absorbed dose The Kerma (Kinetic Energy Released in Matter The activity The air kerma-rate constant, Relationship Between the Quantities Reference Air Kerma Rate

Table of Contents (continue)

Recommendations For Recording and
Reporting

Parameters Required for Recording and Reporting Priority

Practical Applications of the Recommendations

Temporary Implants Permanent Implant Single Stationary Source Line Moving Sources Surface Applicators

Introduction
With the introduction of miniaturized brachytherapy sources, the sophisticated 3-D source localization methods have been introduced, which can be linked to computerized methods for dose calculation. Therefore, a common language is valuable to provide a method of dose specification and reporting which can be used for implants of all types of interstitial brachytherapy procedures.

Introduction (continue)
1985: ICRU Report 38, Was written regarding volume specification reporting intracavitary in GYN. the Dose and as well as Brachytherapy

1997: ICRU Report 58, Was written to generate a guideline about the dose specification and reporting for interstitial Brachytherapy

Introduction (continue)

The aim of the report 58 develop a common language based on the presently concepts.

was to that was existing

In this presentation, the ICRU-58 recommended concepts and procedures for dose specifications and reporting of the interstitial brachytherapy implants will be reviewed.

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Definitions of Terms and Concepts Temporary

The radioactive sources are removed from the tissue after the treatment is completed Permanent Implants The brachytherapy sources remain in the patient, and they will not be removed.

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Traditionally,

Definitions of Terms and Concepts (Continue)

the temporary implants were performed with the linear (wires) radioactive sources or seeds arranged in a linear fashion (i.e. ribbons, etc.). However, in a permanent implants, multiple loose sources were distributed in random orientations.

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Definitions of Terms and Concepts (Continue)

With the design of the low energy

radioactive sources in the form of stranded seeds or radioactive wires, now the permanent implant can also be performed with linear or prearranged ribbons. The loose seed implants are considered separately in this report.

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Definitions of Terms and Concepts (Continue)

Planning temporary implants, The total time of implantation depends on a. Number of sources, b. Strengths and source c. Pattern of distribution of sources

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Definitions of Terms and Concepts (Continue)

Planning permanent implants, The number of sources depends on a. Their initial strength, b. Type of the radioisotope.

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Definitions of Terms and Concepts (Continue)

Planning Boost permanent and temporary implants, The number of seeds and the initial activity of the seeds are adjusted upon the external beam radiation dose.

Definition of Quantities

Absorbed dose
The mean energy imparted by the radiation to a unit mass of medium

The Kerma (Kinetic Energy Released in Matter

The sum of the initial kinetic energies of all the ionizing charged particles liberated by uncharged ionizing particles.

d D= dm

1Gy = 1J/Kg

K=

dE tr dm

1Gy = 1J/Kg

 The activity

Definition of Quantities (continue)

Number of disintegration of a radioactive nucleus per second (dps).

The air kerma-rate constant, ,

Where is the air kerma rate due to photons of energy greater than , at a distance, l , from a point source, with activity of A.
& K

d A= dt
2

The SI unit : s-1

& = l K A

The SI unit : J.kg-1m2

Definition of Quantities (continue)

Relationship Between the Quantities

Where:
tr m D = K (1 g ) m air air

g = part of the kerma that is lost to bremsstrahlung in medium.

Reference Air Kerma Rate

(tr ) = energy transfer coefficient for the medium tr

Reference Air Kerma Rate = Air Kerma Rate at a reference point of 1 cm or 1 m

2 h-1 -1 = 1 cGy cm2 2 h-1 -1 1U = 1 Gy m2

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Source Strength Specification

Pre-1995 a. App. mCi (Aapp) b. mgRaEq. Post-1995 (TG-43 recommendation) a. air kerma strength Gy . h-1. m-1 or
cGy . h-1. cm-1 (U)

Total Reference Air Kerma (TRAK)

TRAK = t . S
i
Where;

Si = Reference air kerma rate for each source ti = Irradiation time for each source This quantity is analogous to mg.h

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Description of Source Patterns

single plane: implant is defined as an

implant containing two or more sources, which lie in the same plane

two-plane (double-plane): implant

contains two planes, which are generally parallel to each other

Multi-plane: implant, contains three or

more planes

non-planer: sphere or cylinder

Volume and Planes (ICRU 50)

GTV CTV PTV TV IV

Volume and Planes

Gross Tumor Volume (GTV)

The palpable or visible/demonstrable extent and location of the malignant growth.

Clinical Volume (CTV)

The volume of the tissue that contains a gross tumor volume and/or subclinical microscopic malignant disease which has to be eliminated.

 Planning Target Volume (PTV)

Volume and Planes (continue)

The volume of tissue receiving the prescribed irradiation. For an interstitial brachytherapy, the PTV is, in general, identical to the CTV.

Treatment Volume (TV)

The volume of tissue, which is encompassed by an isodose surface that has been specified by the radiation oncologist.
The dose value at this isodose surface is the minimum target dose

CTV

The maximum diameters measured in three orthogonal directions must be reported

Central Plane

The plane that is perpendicular to the main

direction of the linear sources and passing through the estimated center of the implant.

 The plane that is perpendicular to the main

direction of the linear sources and passing through the estimated center of the implant.

Central Plane (continue)

Description of Dose Distribution

Interstitial Brachytherapy Implants:

Non Homogeneous dose distribution High Regions around the sources Regions of plateau dose or local minimum doses

Dose Distribution in One or More Planes Through the Implant

The minimum information needed for the dose distribution of an implant is, The isodose curves in at least one plane either in tabular form or by graphical presentation

The central plane of the implant should

be used, If only one plane is chosen.

Prescription Dose
The prescribed dose is defined as the dose, which the physician intends to give, and enters in the patients treatment chart.

Minimum Target Dose (MTD):

The minimum dose at the periphery of the CTV = Minimum dose decided upon by the clinician as adequate to treat the CTV (minimum peripheral dose). MTD 90% of the prescribed dose in the Manchester system for interstitial therapy

Prescription Dose (continue)

Mean Central Dose (MCD) : Dm

The minimum dose at the periphery of the CTV = Arithmetic mean of the local minimum doses between sources, in the central planes.

Prescription Dose (continue)

Mean Central Dose (MCD) : Dm

Prescription Dose (continue)

High Dose Volume

The volume of tissue that is encompassed that will receive more than 150% of the mean central dose be reported.

Low Dose Volume

A low dose volume should be defined as a volume within the clinical target volume, encompassed by an isodose corresponding to 90% of the prescribed dose. The maximum dimension of the low dose volume in any plane calculated should be reported.

Prescription Dose (continue)

i. ii.

Dose Uniformity Parameters The spread of the individual minimum doses used to calculate the mean central dose in the central plane (expressed as a percentage of the mean central dose). The dose homogeneity index; defined as the ratio of minimum target dose to the mean central dose.

ICRU defines the following two methods for the dose uniformity

Time Dose Factors

Time and Dose Rates for Temporary Implants

Time = Prescribed dose/initial dose rate

Time Dose Pattern for Temporary Implants

a. b. c.

Continuous irradiation Non-continuous irradiation Pulsed irradiation

Recommendations for Recording and Reporting

Parameters Required for Recording and Reporting

Description of Volumes : GTV, PTV, . Description of Sources : Radioisotope and filtration Pattern of source distribution Description of Technique and Source pattern

Practical Applications of the Recommendations

Temporary Implants : Table 1. Permanent Implant: Table 2 Single Stationary Source Line: Table 3 Moving Sources: Table 4 Surface Applicators : Table 5

Table 1: Levels of priority for reporting

temporary interstitial implants
Parameters for reporting temporary interstitial implants
Description of Volume (3.A.i):
Gross Tumor Volume Clinical Target Volume Treated Volume (2.6.4)

Prioritya

Levelb of computation
1 1 3 1

1 1 1 1

Description of Source and Technique (3.A.ii, 3.A.iii)

Radionuclide, type of sourc Source size and shape, source pattern Reference air Kerma rate Inactivity vector (applicator), if any

Description of Time Pattern (3.A.iv) Total Reference Air Kerma (3.A.v)

1 1

1 1

Table 1: Levels of priority for reporting

temporary interstitial implants (Cont.)

Parameters for reporting temporary interstitial implants
Description of Dose (3.A.vi):

Prioritya

Levelb of computation
1 2 2 3 3 3 3

a. Prescribed dose including point or surface

of prescriptionc. Reference Dose in Central Plane a. Mean Central Dose b. Minimum Target Dos

1 1 1

Description of High and Low Dose volume (2.F.vi,2.F.vii) Uniformity Parameters (2.6.8) Alternative Representation of Dose Distribution (2.F.ix) Dose Rates at point or surface of prescription (2.G.ii, 2.G.iii)

2 3 3 3

a. 1 2

3 b. 1. 2. 3.

Priority Concerned with doses in the central plan Required calculations outside the central plan. If this is not available, then a more detailed description of source pattern under priority 1 is required. Additional information mostly of clinical research interest Level of computation No computer needed Hand calculation and/or computer calculation in central plane. 3-D computation needed Essential to establish consistent reporting and related to past experience, necessary for comparison of brachytherapy data and for relating outcome to treatment. If a classical system is used, the system should be identified.

c.

Table 2: Levels of priority for reporting permanent interstitial implants.

Parameters for reporting permanent interstitial implants
Description of Volume (3.A.i): Gross Tumor Volume Clinical Target Volume Treated Volume (2.6.4) Description of Source and Technique (3.A.ii, 3.A.iii) Radionuclide, type of source Source size and shape, source pattern Reference air Kerma rate Inactivity vector (applicator), if any 1 1 1 1 1 1 3 1

Prioritya

Levelb of computation

Total Reference Air Kermac (3.A.v) Description of Dose (3.A.vi): Prescribed dose including method of prescription. Reference Dose in Central Plane a. Mean Central Dose b. Minimum Target Dose Description of High and Low Dose volume (2.F.vi,2.F.vii)

1 1 1 2

1 2 2 3

Uniformity Parameters (2.F.viii) Alternative Representation of Dose Distribution (2.F.ix)

3 3

3 3

Table 3: Levels of priority for reporting implants with a single stationary source line.
Parameters for reporting implants with a single stationary source line
Description of Volume (3.B.1): Gross Tumor Volume Clinical Target Volume Treated Volume Description of Source and Technique (3.A.ii, 3.A.iii) RadioNuclide Length and Shape (Straight/Curved) Reference air Kerma rate Strength distribution (uniform linear strength is assumed, if not, distribution must be specified.) Diameter of inactive vector (applicator) Description of Time Pattern (3.A.iv) Total Reference Air Kerma (3.A.v) Description of Dose and Prescription point (Distance from the source line position along the source line) Minimum target dose if different from prescribed dose Dose at 1 cm from axis of the source line at its center Dose at the surface of applicator in contact with tissue Additional representation of dose distribution (2.F.ix) Dose Rate: Average overall treated dose rate at the point or surface of dose prescription (2.G.II, 2.G.III) 1 1 1 1 1 1 3 1

Prioritya

Levelb of computation

1 1 1

1 1 1

1 1 3 3

1 1 3 3

Table 4: Levels of priority for reporting implants with a moving source.

Parameters for reporting temporary interstitial implants
Description of Volume (3.A.i): Gross Tumor Volume Clinical Target Volume Treated Volume (2.F.iv) Description of Source and Technique (3.A.ii, 3.A.iii) Radionuclide, source type and source Type of movement Range of motion (effective length of source) Applicator-including diameter of inactive vector. Number of inactive vectors Reference air kerma rate Description of Time Pattern (2.G.iii) Intervals between fractions Irradiation time per fraction Total Reference Air Kerma (3.A.v) Description of Dose (3.A.vi): Prescribed dose Minimum target dose For single source line or bifurcation, dose at 1 cm For complex implant, mean central dose Method of dose optimization, if applicable Description of high and low dose volume (2.F.vi, 2.F.vii) Uniformity Parameters Additional representation of dose distribution (2.F.ix) Alternative Representation of Dose Distribution (2.F.ix) Dose Rates at point or surface of prescription (2.G.ii, 2.G.iii) 1 1 1 1 1 2 2 3 3 3 1 1 2 2 2 3 2 3 3 3 1 1 1 1 1 1 3 1

Prioritya

Levelb of computation

Table 5: Levels of priority for reporting implants with a surface applicators.

Parameters for reporting use of surface applicators
Description of Clinical Target Volume (3.A.i): Treated Volume (2.F.iv) Description of Applicator ( 3.A.iii) Shape (flat/curved, round/square, etc.) Size Description of source (3.A.ii) Radionuclide and chemical form Concentration (seeds/tubes/plated)c Description of Time Pattern (2.G.iii) Intervals between fractions Irradiation time per fraction Total Reference Air Kerma (3.A.v) Description of Dose (3.A.vi): Prescription Dose and point of dose prescription Dose at 5 mm in tissue at the center of the applicatord Minimum target dosee Description of high dose at tissue surface in contact with applicator, usually near the center of the applicator. Uniformity Parameters Additional representation of dose distribution (2.F.ix) Dose Rates: Average dose rate at the point of dose prescription (2.G.II) 3 3 1 1 1 1 1 1

Prioritya
1 1 1

Levelb of computation
1 3 1

1 1 1 2 3

1 2 2 2 3

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