Week 9 Lecture 1:
BRACHYTHERAPY Fundamentals (continued)
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Occupational Radiation Protection
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Areas where brachytherapy has been
used.
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2. Implant techniques and
applicators
Permanent implants
patient discharged with implant in place
Temporary implants
implant removed before patient is discharged from hospital
Part 6, lecture 2: Brachytherapy techniques
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2.1 Permanent implants
Implantation of sealed sources (typically seeds)
into the target organ of the patient
Sources are NOT removed and patient is
discharged with activity in situ
Part 6, lecture 2: Brachytherapy techniques
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Source requirement for permanent
implants
Low energy gammas or betas to minimize radiation levels
outside of the patient (125-I is a good isotope)
May be short-lived to reduce dose with time (198-Au is a good
isotope)
Part 6, lecture 2: Brachytherapy techniques
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2.2 Temporary implants
Implant of activity in theatre
Manual afterloading
Remote afterloading
Part 6, lecture 2: Brachytherapy techniques
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Implant of activity in theatre
(Common for permanent implants)
For temporary implants common practice 40 years ago when radium
was commonly used
for example, gynecological implants of radium or 137-Cs needles
Today only very rarely used for temporary implants - one of few
examples are 192Ir hairpins for tongue implants
Part 6, lecture 2: Brachytherapy techniques
9 Historical problems with handling activity in the
operating
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Potential of lost Radiation protection of staff may
sources require awkward operation
The time to place the
sources in the best
possible locations is
typically limited
Part 6, lecture 2: Brachytherapy techniques
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Afterloading
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Implant only empty applicator or needles/catheters in theatre
Once patient has recovered, dummy sources are introduced to verify
the location of the applicators (typically using diagnostic X Rays)
The treatment is planned
The sources are introduced into the applicator or needle/catheter
Part 6, lecture 2: Brachytherapy techniques
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Afterloading
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Manual Remote
The sources are driven
The sources are placed
from an intermediate
manually usually by a
safe into the implant
physicist using a machine
The sources are removed (“afterloader”)
only at the end of The sources are
Part 6, lecture 2: Brachytherapy techniques
treatment withdrawn every time
someone enters the
room
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Afterloading advantages
No rush to place the sources in theatre - more time to optimize
the implant
Treatment is verified and planned prior to delivery
Significant advantage in terms of radiation safety (in particular if
a remote afterloader is used)
Part 6, lecture 2: Brachytherapy techniques
Quick question:
Why is afterloading the method of choice from a
radiation safety perspective?
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Some radiation safety aspects of
afterloading
No exposure in theatre
Optimization of medical exposure possible
No transport of a radioactive patient necessary
Part 6, lecture 2: Brachytherapy techniques
‘Live’ implants should be avoided for temporary implants
Applicators for brachytherapy
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3. Delivery
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Low Dose Rate (LDR)
High Dose Rate (HDR)
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Delivery modes - different classifications
are in use
<
Low
1Gy/hour
Dose Rate
around 0.5Gy/hour
>10Gy/hour
High Dose Rate
Part 6, lecture 2: Brachytherapy techniques
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Low dose rate brachytherapy
The only type of brachytherapy possible with manual
afterloading
Most clinical experience available for LDR brachytherapy
Performed with remote afterloaders using 137-Cs or 192-Ir
Part 6, lecture 2: Brachytherapy techniques
Low dose rate brachytherapy
Selectron for gynecological
brachytherapy
137-Cs pellets pushed into
the applicators using
compressed air
6 channels for up to two
parallel treatments
Nucletron
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Simple design
No computer required
Two independent timers
Optical indication of
source locations
Permanent record
through printout
Key to avoid unauthorized
use
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Treatment
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Implant of applicator (typically in the operating theatre)
Verification of applicator positioning using diagnostic X Rays
(e.g. radiotherapy simulator)
Part 6, lecture 2: Brachytherapy techniques
22 Two orthogonal views allow to localize the applicator in
three zdimensions
Part 6, lecture 2: Brachytherapy techniques
3.2 High Dose Rate Brachytherapy
Most modern
brachytherapy is
delivered using HDR
Reasons?
Outpatient procedure
Optimization possible
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HDR
z brachytherapy
Source moves step by step
In the past possible
through using
the applicator 60-Co pellets
- the
dwell times in different locations
Today, virtually
determine all HDR
the dose brachytherapy is delivered using a 192-
distribution
Ir stepping source
Part 6, lecture 2: Brachytherapy techniques
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z Optimization of dose distribution adjusting the
dwell times of the source in an applicator
Part 6, lecture 2: Brachytherapy techniques
Nucletron
HDR brachytherapy procedure
Implant of applicators, catheters or needles in theatre
For prostate implants as shown here use transrectal
ultrasound guidance
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27 HDR brachytherapy procedure
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Localization using diagnostic X Rays
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Treatment planning
Definition of the desired dose distribution
(usually using many points)
Computer optimization of the dwell
positions and times for the treatment
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Treatment
Transfer of date to treatment unit
Connecting patient
Treat...
Gammamed
Part 6, lecture 2: Brachytherapy techniques
Nucletron
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HDR unit
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HDR brachytherapy
Usually fractionated (e.g. 6 fractions of 6Gy)
Either patient has new implant each time or stays in hospital for
bi-daily treatments
Time between treatments should be >6hours to allow normal
tissue to repair all damage
Part 6, lecture 2: Brachytherapy techniques
HDR units: different designs available
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Catheters are indexed to avoid mixing them up
Part 6, lecture 2: Brachytherapy techniques
Transfer catheters are locked into
place during treatment - green light
indicates the catheters in use
HDR systems
Can be moved
between different
facilities or into theatre
for intra-operative work
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Question:
Please list advantages and disadvantages of High Dose Rate Brachytherapy as
compared to Low Dose Rate brachytherapy. Assume both approaches are performed
using remotez afterloading equipment.
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The answer should include:
Advantages Disadvantages
Out patient procedure Potential radiobiological
Optimization of dose disadvantage
distribution using Fractionation required
stepping source More shielding required
Possibly better
There is no time to
geometry as patient intervene if machine
anesthetized failure occurs
Part 6, lecture 2: Brachytherapy techniques
No exposure of nursing
More sophisticated
staff during procedure (and expensive)
No source preparation
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Radiation protection issues
Patients are discharged with radioactive sources in place:
lost sources
exposure of others
issues with accidents to the patient, other medical procedures,
death, autopsies and cremation
Part 6, lecture 2: Brachytherapy techniques
Radiation Protection Issues
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1. Misadministration - the administration of an external beam radiation therapy dose:
A. Involving the wrong patient, wrong treatment modality, or wrong treatment site; or,
B. When the treatment consists of three (3) or fewer fractions and the calculated total administered
dose differs from the total prescribed dose by more than ten (10) percent of the total prescribed dose; or
C. When the calculated weekly administered dose differs from the weekly prescribed dose by more
than thirty (30) percent; or
D. When the calculated total administered dose differs from the total prescribed dose by more than
twenty (20) percent of the total prescribed dose;
2. Prescribed dose - the total dose and dose per fraction as documented in the written directive. The
prescribed dose is an estimation from measured data from a specified therapeutic radiation machine using
assumptions that are clinically acceptable for that treatment technique and historically consistent with the
clinical calculations previously used for patients treated with the same clinical technique;
3. Recordable event - the administration of an external beam radiation therapy dose when the calculated
weekly administered dose differs by fifteen (15) percent or more from the weekly prescribed dose;
4. Written directive - an order in writing for a specific patient, dated and signed by an authorized user prior to
the administration of radiation, containing the following information: total dose, dose per fraction, treatment site
and overall treatment period.
https://regs.health.ny.gov/content/section-1625-misadministrations
An I-125 seed is used in a COMS eye plaque procedure has
z a dose rate of 75c Gy per hour. It is placed strategically at
the back of the retina to deliver 2700 cGy to a uveal
melanoma site. If it is placed inside the plaque at 8 am on
Monday morning and was taken off at 8 am on Wednesday
morning – has a misadministration occurred?
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If the gold plaque has an HVL of 0.025 mm, how much dose was deposited
at the end of a 2700 cGy-treatment regimen to the optic nerve which is
located behind the 2-mm thick gold plaque? How many rems has it received?
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