RT06 Brachy2a Techniques WEB

IAEA Training Material on Radiation Protection in Radiotherapy
Radiation Protection in Radiotherapy

Part 6 Brachytherapy Lecture 2: Brachytherapy Techniques
Brachytherapy

Very flexible radiotherapy delivery Source position determines treatment success Depends on operator skill and experience In principle the ultimate conformal radiotherapy Highly individualized for each patient Typically an inpatient procedure as opposed to external beam radiotherapy which is usually administered in an outpatient setting
Part 6, lecture 2: Brachytherapy techniques 2
Objectives
To be familiar with different implant
techniques To be aware of differences between permanent implants, low (LDR) and high dose rate (HDR) applications To appreciate the potential for optimization in high dose rate brachytherapy To be familiar with some special techniques used in modern brachytherapy (seed implants, endovascular brachytherapy)
Contents
1. Clinical brachytherapy applications 2. Implant techniques and applicators 3. Delivery modes and equipment 4. Special techniques A. Prostate seed implants B. Endovascular brachytherapy C. Ophthalmic applicators
Part 6, lecture 2: Brachytherapy techniques
Clinical brachytherapy
History
Brachytherapy has been one of the earliest
forms of radiotherapy After discovery of radium by M Curie, radium was used for brachytherapy already late 19th century There is a wide range of applications - this versatility has been one of the most important features of brachytherapy
Today
Many different techniques and a large

variety of equipment Less than 10% of radiotherapy patients receive brachytherapy Use depends very much on training and skill of clinicians and access to operating theatre
A brachytherapy patient
Typically localized cancer Often relatively small tumour Often good performance status (must
tolerate the operation) Sometimes pre-irradiated with external beam radiotherapy (EBT) Often treated with combination brachytherapy and EBT
Patient flow in brachytherapy

Treatment decision Ideal plan - determines source number and location Implant of sources or applicators in theatre Localization of sources or applicators (typically using X Rays) Treatment plan
Commence treatment
1. Clinical brachytherapy applications
A. Surface moulds B. Intracavitary (gynaecological, bronchus,..) C. Interstitial (Breast, Tongue, Sarcomas, ) not covered here: unsealed source radiotherapy (Thyroid, Bone metastasis, ) - this is dealt with in the IAEA training material on radiation protection in Nuclear Medicine
A. Surface moulds
Treatment of superficial lesions with
radioactive sources in close contact with the skin
Hand A mould for the back of a hand including shielding designed to protect the patient during treatment
Catheters for source transfer

Historical example
Surface applicator with irregular distribution of radium on the applicator surface (Murdoch, Brussels 1933)
12
Other example
Treatment of squamous cell carcinoma of the forehead
Catheters for source placement

Source distance from the skin

Determines incident dose Determines dose fall off in skin - the further
the sources are from the skin the less influence has dose fall off due to inverse square law Dose homogeneity - the further away the sources are the more homogenous the dose distribution is at the skin
Simulator films of forehead mould
Dummy wires as markers for location
Surface mould advantages

Fast dose fall off in tissues Can conform the activity to any surface Flaps available
17
B. Intracavitary implants
Introduction of radioactivity using an

applicator placed in a body cavity Gynaecological implants Bronchus Oesophagus Rectum
18
Gynaecological implants
Most common
brachytherapy application cervix cancer Many different applicators Either as monotherapy or in addition to external beam therapy as a boost
19
Gynecological applicators
Different design - all Nucletron
20
Vaginal applicators
Single source line Different diameters
and length
Gammamed - on the right with shielding
Nucletron
21
Bronchus implants
Often palliative to open
air ways Usually HDR brachytherapy Most often single catheter, however also dual catheter possible
22
Dual catheter bronchus implant

Catheter placement via
bronchoscope Bifurcation may create complex dosimetry
23
C. Interstitial implants
Implant of needles or flexible catheters

directly in the target area Breast Head and Neck Sarcomas Requires surgery - often major
24
Interstitial implants - tongue implant

Catheter loop
tongue
Button
tongue
25
Breast implants
Typically a boost Often utilizes templates to improve source
positioning Catheters or needles
26
2. Implant techniques and applicators
Permanent implants
patient discharged with implant in place Temporary implants implant removed before patient is discharged
from hospital
27
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 (compare part 16 of the course)
28
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
Discussed in more detail in parts 9 (Medical Exposure), 16 (Discharge of patients) and 17 (Public exposure)
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) More details on most common 125-I prostate implants in section 4A of the lecture
30
Temporary implants
Implant of activity in theatre Manual afterloading Remote afterloading
31
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
32
Problems with handling activity in the operating theatre

Potential of lost
sources The time to place the sources in the best possible locations is typically limited
Radiation protection of staff may

require awkward operation
33
Afterloading
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
34
Afterloading
Manual
The sources are placed
manually usually by a physicist The sources are removed only at the end of treatment
Remote
The sources are driven
from an intermediate safe into the implant using a machine (afterloader) The sources are withdrawn every time someone enters the room
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)
37
Quick question:
Why is afterloading the method of choice from a radiation safety perspective?
Some radiation safety aspects of afterloading
No exposure in theatre Optimization of medical exposure possible No transport of a radioactive patient

necessary
Live implants should be avoided for temporary implants
39
Applicators for brachytherapy
40
Brachytherapy Applicators - lots to choose from, lots to learn
41
Some examples for applicators
Gynaecological applicators
Fletcher Suit
Ring type
Henschke type
42
Rotterdam Applicator
A choice of sizes allows customized
treatment of each patient
Tandem Lengths (in mm) 40 50 60 70

Ovoid Sizes Small Medium Large
43
Close-up view
44
Other intracavitary applicators

Vaginal Bronchus
45
Interstitial applicators
Needles
hollow and rigid may use templates
for placement usually have pusher during implantation in tissue
Interstitial applicators
Catheters
flexible open and closed end
available often introduced into tissue via an open end needle
skin
3. Delivery modes and equipment

Low Dose Rate (LDR) Medium Dose Rate (MDR) High Dose Rate (HDR) Pulsed Dose Rate (PDR)
48
Delivery modes - different classifications are in use

Low Dose Rate Medium Dose Rate
< 1Gy/hour around 0.5Gy/hour > 1Gy/hour not often used >10Gy/hour pulses of around 1Gy/hour
High Dose Rate Pulsed Dose Rate
49
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
50
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
Simple design
No computer required Two independent
timers Optical indication of source locations Permanent record through printout Key to avoid unauthorized use
Treatment process
Implant of applicator (typically in the
operating theatre) Verification of applicator positioning using diagnostic X Rays (e.g. radiotherapy simulator)
53
Two orthogonal views allow to localize the applicator in three dimensions
54
Treatment planning
Most commercial treatment planning
systems have a module suitable for brachytherapy planning: Choosing best source configuration Calculate dose distribution Determine time required to give desired
dose at prescription points Record dose to critical structures
Treatment planning of different brachytherapy implants
56
High Dose Rate Brachytherapy

Most modern
brachytherapy is delivered using HDR Reasons?
Outpatient procedure Optimization possible
57
HDR brachytherapy
In the past possible using 60-Co pellets Today, virtually all HDR brachytherapy is
delivered using a 192-Ir stepping source
Source moves step by step through the applicator - the dwell times in different locations determine the dose distribution
58
HDR 192-Ir source
Source length 5mm, diameter 0.6mm Activity: around 10Ci
From presentation by Pia et al.

59
Optimization of dose distribution adjusting the dwell times of the source in an applicator
Nucletron
60
HDR brachytherapy procedure

Implant of applicators, catheters or needles in theatre For prostate implants as shown here use transrectal
ultrasound guidance
61
HDR brachytherapy procedure

Localization using diagnostic X Rays
62
Treatment planning
Definition of the desired
dose distribution (usually using many points) Computer optimization of the dwell positions and times for the treatment
63
Treatment
Transfer of date to treatment
unit Connecting patient Treat...
Gammamed
Nucletron
HDR unit interface
65
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
66
HDR units: different designs available
67
Catheters are indexed to avoid mixing them up
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
69
Pulsed dose rate

Unit has a similar design as HDR, however the
activity is smaller (around 1Ci instead of 10Ci) Stepping source operation - same optimization possible as in HDR Treatment over same time as LDR treatment to mimic favorable radiobiology In-patient treatment: hospitalization required Source steps out for about 10 minutes per hour and then retracts. Repeats this every hour to deliver minifractions (pulses) of about 1Gy
70
Pulsed dose rate brachytherapy

Different dose/time
pattern possible Usually treatment about once per hour Illustration form ICRU report 58
71
Features of PDR:
Advantages
Emulates LDR Optimized dose
distribution Visitors and nursing staff can use the time between pulses while the activity is in the safe
Disadvantages
- Potential radiation safety
hazard of a source stuck in the patient:
In LDR - low activity, no severe
problem In HDR - physicist is present during treatment In PDR - will someone with sufficient training be there within 10 minutes? Even at midnight???
72
Question:
Please list advantages and disadvantages of High Dose Rate Brachytherapy as compared to Low Dose Rate brachytherapy. Assume both approaches are performed using remote afterloading equipment.
The answer should include:

Advantages
Out patient procedure Optimization of dose
distribution using stepping source Possibly better geometry as patient anesthetized No exposure of nursing staff during procedure No source preparation
Disadvantages
Potential
radiobiological disadvantage Fractionation required More shielding required There is no time to intervene if machine failure occurs More sophisticated (and expensive)

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IAEA Training Material on Radiation Protection in Radiotherapy

Radiation Protection in Radiotherapy

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Many different techniques and a large

Patient flow in brachytherapy

1. Clinical brachytherapy applications

Catheters for source transfer

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Catheters for source placement

Radiation Protection in Radiotherapy

Source distance from the skin

Simulator films of forehead mould

Dummy wires as markers for location

Surface mould advantages

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Introduction of radioactivity using an

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Different design - all Nucletron

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Dual catheter bronchus implant

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Implant of needles or flexible catheters

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Interstitial implants - tongue implant

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

2. Implant techniques and applicators

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation protection issues

Source requirement for permanent implants

Low energy gammas or betas to minimize

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Implant of activity in theatre

Today only very rarely used for temporary

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques

Problems with handling activity in the operating theatre

Radiation protection of staff may

Radiation Protection in Radiotherapy

Part 6, lecture 2: Brachytherapy techniques