Physics

y
and Dosimetry
y of the INTRABEAM System:
y
an Intraoperative Brachytherapy Platform
Susha Pillai and Junan Zhang

Scheme

Intrabeam System
y
Physics
Dosimetry/Radiobiology
Clinical Study
QA/Workflow

Carl Zeiss INTRABEAM System

Designed for mobile electronic

brachytherapy.
Perform IORT treatment in OR, with no
special radiation shielding requirements.
Manufactured
M
f t db
by C
Carll Z
Zeiss
i S
Surgical
i l,
Germany, which acquired Intrabeam as the
asset of Photoelectron Corp, USA
(bankrupted.)
Received FDA approval for intraoperative
treatment in1999.
Received
R
i d approvall in
i 2005 tto ttreatt whole
h l
body use.- skin, gynecological applications
Operates at 50kVp (breast)/40kVp (brain)
and
d 40
40A.
A

Surgical removal of the tumor

Applicator with X-ray probe positioned in

the lumpectomy site. Treatment last for
about 20 to 50minute to deliver 20Gy in
single fraction to the applicator surface

Intrabeam Radiotherapy system components

INTRABEAM X-ray Source (XRS 4)
X-ray probe (XRS unit)
Energy (max.): 50 kV, 40 A
Weight: approximately 1.6 kg
Miniature X-ray source
Dimensions (L x W x H in cm): 17.5 x 11 x 7
10cm long 3.2mm diameter probe
Gold target
Operates under 50kVp/40 A or 40kVp/40 A.
Low energy X-rays emitted isotropic pattern
Internal Radiation Monitor (IRM)
Continuously monitor the treatment delivery
It is a measure of the radiation re-eneters the probe

Beam Deflector

Probe

Probe tip
Internal Radiation Monitor

Spherical Applicators
A set of spherical
p
applicators
pp
to adapt
p for varying
y g tumor size
Made of polyetherimide (C37H24O6N2)
Size ranging from 1.5cm to 5.0cm with 5mm increment
Reusable up to 100 sterilization cycles, biocompatible and
radiation resistant
can be steam sterilized

Intrabeam Surgical Carrier System

6 degrees of freedom
Weight compensation
Magnetic brakes
Easy, flexible and precise probe placement in the treatment area.
Intrabeam cart
To store all treatment and QA compoenents
Easy transportation to/from OR room
QA check can be performed on the cart
To avoid schedule OR room for the QA.

Scheme

Intrabeam System
y
Physics
Dosimetry/Radiobiology
Clinical Study
QA/Workflow

X-ray probe and dose distribution

Cutaway view of the intrabeam probe

4. Internal radiation
monitor

3. No high
g voltage
g
outside of the tube
housing to ensure
patient and personnel
safety

1. Probe tip
p ((made of beryllium,
y
,
allowing x-ray to pass through).
Coated with a film of nickel and
titanium nitride.

2. Made of Mu-metal. Shield the Earths

magnetic field (0.5 G). Sensitivity
(0.06mm/G)

Cutaway view of the intrabeam probe

Beam hardening and depth dose curve

Beam attenuated by approximately r-3

The first HVL is 0.11 mm Al for breast

treatment (50kVp) and 1.11 mmAl (23.5keV)
at 10 mm depth in Solid Water.
The first HVL is 0.10 mm Al for brain
treatment (40kVp) and 0.71 mmAl (19.9keV)
at 10 mm depth
p in Solid water.

50kVp, 40A

Scheme

Intrabeam System
y
Physics
Dosimetry/Radiobiology
Clinical Study
QA/Workflow

Prescription Dose

20 Gy
G att the
th applicator
li t surface
f
and
d
5-6 Gy at 1cm tissue depth.
Radiobiological view:

Relative biological effectiveness (RBE)

Is the dose tolerable?
I the
Is
th d
dose sufficient?
ffi i t?
Figure adapted from JS. Vaidya 2005

Relative Biological Effectiveness (RBE)

RBE iis defined

d fi d as Dref/Dtx, where
h
Dref/Dtx, are
respectively the doses of reference radiation
and treatment radiation required for equal
biological effect.
effect
Typically, reference radiation is 250-kV X-ray
or Co-60 X-ray. We choose Co-60 in this
discussion.
discussion
As a example, to achieve 0.01 survival level,
Dneutron =7Gy, Dref = 10.5Gy.
=>RBE=10 5/7=1 5
=>RBE=10.5/7=1.5
Biologically weighted Dose
=dose XRBE=7Gyx1.5=10.5Sv(Gy).
Higher RBE=> Higher Biological Dose

Figure adapted from Halls book

Relative Biological Effectiveness (RBE)

RBE(Intrabeam)?
RBE(I
t b
)?
depends on Linear Energy Transfer (LET)
depends on cell surviving level
depends on treatment time

Photon Interactions

Photon interaction generates

secondary electrons though
photoelectric effect or Compton
scattering.

In PE,

In CS

E k h E b
Ek h

1 cos
1 1 cos

where =hv/moc2

Electron Range

Thumb rule: electron range in

water is about E(MeV)/2 cm
In other words, all megavoltage
electron beams lose kinetic
energy in a similar rate,
linear stopping power
dE/dx = 2 MeV/cm
=2,000 keV/ 10,000 m
=0.2 keV/m

Whatt is
Wh
i dE/dx
dE/d for
f kilovoltage
kil
lt
electrons?

Bremsstrahlung

Radiation energy loss through

bremsstrahlung production.
The lost energy is converted into
X-ray.
In water/tissue, radiation energy
loss is relatively small.

Collisional Energy Loss

Electrons lose kinetic energy through

electron-orbital
l t
bit l electron
l t
collision,
lli i
causing
i
ionizations.
This energy loss rate is called linear energy
dEion
t
transfer
f (LET)

LET

dx

Slow electrons get more scattering than fast

electrons per track length

LET

v electron

E p 2 Ft v 2
2

LET for Secondary Electrons

LET(>1MeV)=2 MeV/cm
=0.2 kev/m
LET(10keV)= 20 MeV/cm
= 2.0 keV/m
Kilovoltage x-ray has higher LET (of
secondary electrons) than
Megavoltage xx-ray.
ray

RBE varies with LET

Relative Biological Effectiveness (RBE)

RBE(Intrabeam)?
depends on Linear Energy Transfer (LET)
depends
d
d on cellll surviving
i i llevell
depends on treatment time

Relative Biological Effectiveness (RBE)

RBE also
l depends
d
d on cellll survival
i l llevel,
l
and corresponding radiation dose.

As a example, at 0.01 survival level,

RBE(neutron)=1050/700=1.5
At 0.7 level, RBE(neutron)=300/100=3.0

Figure adapted from Halls book

RBE varies with LET and cell survival level

Linear Quadratic Model

Cellll survival
C
i l S e D D
Find Dref to achieve the same cell
survival level caused by DIORT .
To achieve the same cell survival level
level.
2

2
2
IORT DIORT IORT DIORT
ref Dref ref Dref

Solving the equation

RBE ( IORT w.r.t. ref )

ref

Dreff
DIORT

IORT

DIORT
DIORT 1

ref
ref

2 DIORT
ref

a IORT ref
Dref 0

IORT ref DIORT

Chapmens experiment(1977)

Chinese hamster cells.

The value increases with LET until
reaches a maximal around 100-150
keV/m
The value
Th
l does
d
nott change
h
ttoo much
h
and can be considered as a constant.

RBE for intrabeam treatment

Beam
hardening

RBE ( DIORT 0)

IORT
Co60

For low dose regime ,

RBE d
decreases with
ith
depth due to beam
hardening

RBE for intrabeam treatment

For high dose regime , RBE

i
increases
with
ith d
depth
th d
due to
t
dose attenuation

Relative Biological Effectiveness (RBE)

RBE?
depends on Linear Energy Transfer (LET)
depends on cell surviving level
depends on treatment time

After considering cell repairing during tx time.

RBE from radiobiology experiment

RBE and Equivalent Dose of Intrabeam

Depth

Physical
Dose

RBE

Equivalent
Dose

Surface
10mm
25 mm

20 Gy
5-6 Gy
~2 Gy

1~1.2
1.5
2

20-25 Gy
~8 Gy
~4 Gy

Biological dose decreases slower than physical dose as

the depth increases.

Fractionation effect
2
aDIORT DIORT
n( a ( 2Gy ) ( 2Gy ) 2 )

30 a 10G early responding

22Gy 1 22Gy / a

n
2Gy[1 2Gy / a ]
55 a 3G late responding

It is estimated that an external-beam dose of 60 Gy given in 30 fractions

at 2 Gy per fraction is equivalent to a single intraoperative radiotherapy
fraction of 2022 Gy (with an / ratio at 10 Gy considered typical for
tumours and acutely reacting tissues).
With this same regimen, but when the tolerance of late-responding
tissues (/ ratio at 3 Gy) is taken in to consideration, the equivalent
value is at least 110 Gy
Gy.
However, the linear-quadratic model is reliable only for single doses up to
68 Gy, and therefore might not be appropriate for modeling the effects
of higher single doses (2025
(20 25 Gy) used in intraoperative radiotherapy or
radiosurgery.

Scheme

Intrabeam System
y
Physics
Dosimetry/Radiobiology
Clinical Study
QA/Workflow

TARGIT-A trial

Ph
Phase III study:
t d effectiveness
ff ti
off Intrabeam
I t b
th
therapy
for
f
prevention of local breast ca recurrence
g
Rationale: 90% of local recurrence occur near the original
tumor location (index quadrant).
Randomized study conducted in 28 centers in 9 countries.
2232 breast cancer patients; 1113 was scheduled for
intrabeam therapy
Rest was scheduled for conventional whole breast therapy.
age over 45 or older with uni-focal invasive ductal carcinoma.
Breast conserving surgery before therapy.
Four years follow up

Local Recurrence

Two
T
o trail arms sho
showed
ed no significant
difference in local recurrence:
1.2% for TARGIT arm vs 0.9% for
control arm
arm. (6 vv.s.
s 5 cases at 4 years)

Clinically significant complications

Incidence rate of major toxicity was similar between two arms

Targeted IORT patients have a higher risk of seroma and delayed wound
healing .
EBRT whole breast patients have a higher risk of RT
RT-related
related complication
complication.

Scheme

Intrabeam System
y
Physics/QA
Dosimetry/Radiobiology
Clinical Study
QA/Workflow

Intrabeam Quality Assurance Tools

Manufacturer provided full set of

radiation shielded QA instruments.
PDA(Photodiode Array)

PIACH (Probe adjuster/ionization

chamber holder)

Mount for
ion
chamber

Contains five photodiodes at orthogonal

positions
Isotropy check

Measures and adjusts the straightness of the

probe manually
Inbuilt thermometer for temperature/pressure
correction
Mount for ionchamber

High precision water phantom

(optional/send back to factory to QA)

To perform independent verification of the

depth dose and Dose distribution
Radiation shielded with lead glass.
M h i l positioning
Mechanical
iti i accuracy off +/
+/0.1mm

PDA

PAICH

Water phantom

Probe straightness

X
X-ray source (XRS) probe
b can nott
be bended. Handle it with care.
Always use V-block
V block guide to insert
XRS into QA devices.

XRS probe straightening (PAICH)

PAICH

Manually straighten the probe

using a plunger if needed
Rotate PAICH 360deg around
the XRS probe
LED/photo detector unit tracks
the probe position
Runout value less than 0.1mm (
~0.07mm)

Plunger

Cross sectional view

XRS probe

Dynamic offset (PDA)

Electronic alignment of the XRS probe

Align the electron beam direction with the
mechanical center of the probe
Steering of electron beam based on the five
Photodiode readings
Mechanical alignment
g
of the p
probe should
followed by Dynamic Offset check.

PDA

XRS

PDA source check

Verify the isotropy of the X-ray beam emits

from the probe tip
Compare the voltage measured by the five photodiodes
located inside the PDA

Measurement off count rate with the Internal

Radiation Monitor (IRM)
IRM is located inside the XRS probe

PAICH output check

Ion chamber

PAICH

Soft X-ray chamber & PTW electrometer

In-air measurement of the current
Corrected for Temperature and pressure
(10% tolerance)

XRS probe
b

PAITCH output (Gy/min) DTreat

= IT.P
(60s/min)
T P (A) * Nk (Gy/C) * kQ *(60s/min)
IT.P is the measured current after temp
pressure correction
correction.
Nk is the dose calibration factor of the parallel
plate IC.
kQ is
i th
the energy correction
ti factor.
f t

PTW Unidos Electrometer

Water phantom

PAICH does not provide

pro ide absolute
absol te doserate
in any water depth.
However since all PAICH units and
ionization chambers features an identical
design, it is possible to compare in-air
measurement at custom side to in-warter
measurement at factory and custom side
and
d thus
th to
t determine
d t
i the
th absolute
b l t dose
d
rate
t
of XRS prior to treatment.
D(Paich) in air Corrected dose in water(XRS probe)
apply transfer function for applicator
apply PDD for the XRS source
= gives you the dose at treatment depth

Intrabeam Treatment Workflow

1)
2)
3)
4)
5)
6)
7)
8)

Applicators sterilized and kept in the OR

QA procedure must be performed within
36hrs of each treatment.
Lumpectomy procedure
A
Assess
the
th cavity
it size
i and
d select
l t th
the
proper applicator
XRS probe and the Intrabeam stand are
covered in a sterile polyethylene bag
S
Secure
th applicator
the
li t to
t the
th XRS probe
b
Position the applicator in the
lumpectomy cavity
(Surgeon/RadiationOncologist)
If necessary, the chest wall and skin can
be protected (95% shielding) by radioopaque tungsten-filled polyurethane
caps. (avoid significant skin doses that
occur with distances of <1 cm)

Intrabeam Treatment Workflow

9)
10)

11)

12)
13)
14)

Place tungsten-filled drape for shielding

Treatment plan
Entry of treatment parameters
D
Does
nott require
i imaging
i
i
Some centers use ultrasound to
document the distance from the skin
Treatment parameter verification
Applicator size
Prescription dose
Treatment depth
Treatment delivery time is about 20 to
55mins
Radiation survey
Evaluation and documentation of Treatment
records

0.0

Shielding and Radiation Survey

<2 mR/hr

<2 mR/hr
12~15
5
mR/hr

Electronic brachytherapy

Currently, there are two electronic

brachytherapy (EBT) devices available for
partial breast irradiation
irradiation.

The End

Thank you!