PHYSICS OF BRACHYTHERAPY

[Link]
Sri Shankara Cancer Hospital & Research Centre
Bengaluru 560 004.
 Introduction
• Brachytherapy (also referred to as Curietherapy) is defined as
a short-distance treatment of malignant disease with
radiation emanating from small sealed (encapsulated)
sources.
• The sources are placed directly into the treatment volume
or near the treatment volume.
 Introduction
Brachytherapy compared to external beam therapy:
Advantages of brachytherapy
• Improved localized dose delivery to the target
• Sharp dose fall-off outside the target volume
• Better conformal therapy
Disadvantages of brachytherapy
• Only good for well localized tumors
• Only good for small lesions
• Very labor intensive
 Brachytherapy sources
Photon sources
Emit gamma rays through gamma decay and possibly characteristic
x rays through electron capture and internal conversion
(examples: Co-60, Cs-137, Ir-192, I-125, Pd-103)
Beta sources
Emit electrons following beta source decay
(example: Sr-90/Y-90)
Neutron sources
Emit neutrons following spontaneous nuclear fission
(example: Cf-252)
 Types of brachytherapy Techniques
Intracavitary: Sources are placed into a body cavity.
Interstitial: Sources are implanted into the tumor volume.
Surface plaque: Sources are loaded into a plaque which is brought into
contact with a skin surface lesion.
Intraluminal: Sources are inserted into a lumen.
Intraoperative: Sources are brought surgically into or near the tumor.
volume.
Intravascular: Sources are brought intravascularly into a lesion or
near a lesion.
 classification with treatment duration
Temporary implant
• Dose is delivered over a period of time that is short in comparison
with the half-life of the sources.
• Sources are removed when the prescribed dose has been reached.
Permanent implant
• Dose is delivered over the lifetime of the sources.
• The sources undergo complete radioactive decay.
 classification with type of source loading
Hot loading
• Applicator is pre-loaded and contains radioactive sources at time of
placement into the patient.
Afterloading
• Applicator is placed first into the patient and the radioactive sources
are loaded later
- Either by hand (manual afterloading)
- Or by machine (automatic remote afterloading)
 Manual afterloading
• Generally, the radiation sources are manually
afterloaded into applicators or catheters that
have been placed within the target volume.
• At the end of treatment the sources are
removed, again manually.
• Manual loading and removal of sources from
the applicators or catheters result in some
radiation exposure to the medical and support
staff.
 Remote afterloading
• To minimize radiation exposure to medical and support staff
several computer driven remote afterloading systems have
been developed.
Advantages over manual procedures
• Increased patient treatment capacity.
• Consistent and reproducible treatment delivery.
• Reduced radiation exposure to staff
Remote After loading Units
 Classification with Dose Rate
Low dose rate (LDR) - 0.4 - 2 Gy/h

Medium dose rate (MDR) - 2 - 12 Gy/h

High dose rate (HDR) - > 12 Gy/h

Pulse Dose Rate - “Dose pulses” of the order of 30 minutes separated

by 1 to several hours (Simulation of LDR)
 Characteristics of Brachytherapy sources

Brachytherapy sources are usually encapsulated and the

capsule serves multiple purposes:

• Contains the radioactivity.

• Provides source rigidity. (70% Iridium & 30% Platinum)
• Absorbs alpha and beta radiation produced through source
decay.
 Characteristics of brachytherapy sources
• Photon energy
• Half-life
• Half-value layer in shielding materials
• Specific activity
• Source strength
• Inverse-square dose fall-off
Photon source characteristics
 PHOTON SOURCE CHARACTERISTICS
Mechanical characteristics of brachytherapy sources
Brachytherapy photon sources are available in various
forms, such as:
• Needles (Caesium-137).
• Tubes (Caesium-137).
• Pellets (Cobalt-60 and Caesium-137).
• Seeds (Iodine-125, Paladium-103, Iridium-192, Gold-198).
• Wires (Iridium-192).
Source Specification
Source Specification
Source Specification
Source Specification
Source Specification
 Specification of beta ray sources
• Beta ray sources are specified as reference absorbed dose rate
in water at a reference distance from the source.

• Reference distance differs from one type of source to another

and is generally between 0.5 mm and 2 mm from the source.
 Gynaecology Dosimetry Systems
• Intracavitary brachytherapy used for treatment of
the cancer of the cervix, uterine body and vagina.
• Various applicators are in use to hold sources in an
appropriate configuration
• A cervical applicator consists of a central tube
(tandem) and lateral capsules (ovoids or colpostats).
 Sources used for Gynaecology application

• The most widely used source for treatment of gynaecological

cancers is Caesium-137.
• It is often necessary to use sources of differing strengths in
order to achieve the desired dose distribution.
• In modern remote afterloading machines Iridium-192 is
the commonly used radionuclide.
• Recently HDR units with Cobalt-60 sources (2Ci) available
 Gynaecology dosimetry systems
• Cancer of the uterus was first treated with radium in 1908.
• Many systems have been designed for dose delivery and
specification.
• The two most commonly used systems for dose specification
in treatment of the cervix are:
• Manchester system
• ICRU system
 Manchester system
Manchester system is characterized by doses to four
points: point A, point B, bladder point, and rectum point.
Duration of the irradiation is based on the dose rate at
point A, which is located 2 cm superior to the cervical
orifice (os) and 2 cm lateral to the cervical canal.
Point B is defined 3 cm laterally to
point A when the central canal is not
displaced.
 Manchester system
Since point A relates to the position of the sources rather
than to a specific anatomic structure, it may lie inside the
tumour or outside the tumour.
If the tandem displaces the central canal, point A moves
with the canal, but point B remains fixed at 5 cm from the
midline.
 ICRU system
Gyneacological dosimetry system relates the dose
distribution to the target volume rather than to a
specific point.
• Report identifies a dose level of 60 Gy as the
appropriate reference dose level for LDR treatments.
• This results in a requirement to specify the
dimensions of the pear-shaped 60 Gy isodose
reference volume
 Intracaitary applicators
• The most commonly used applicator in the treatment of cervical
cancer is the Fletcher-Suit-Delcos system consisting of a
tandem and ovoids.
• The dose distribution delivered by this rigid applicator system
can be optimized by a careful selection and placement of the
sources in the tandem and colpostats
GYNAECOLOGY APPLICATORS
 Rectal and bladder dose monitoring
• Complication result from a high dose delivered to the portions of the
rectum and bladder.
• Applicators should be placed so as to keep the dose to these critical
structures as low as possible.
• Surgical gauze is used to displace the sensitive structures away from
the applicator.
• Measurement of rectal and bladder dose has been attempted using
miniature ionization chambers, scintillation detectors, and MOSFET
dosimeters.
• Measured data give large variability and correlate poorly with
calculated values.
 Interstitial Brachytherapy
In interstitial brachytherapy radioactive sources are
inserted directly into diseased tissue.
With regard to treatment time there are two types of
interstitial implants:
• Temporary.
• Permanent.
With regard to source loading there are three types of
interstitial implants:
• Direct loading.
• Manual afterloading.
• Remote afterloading.
 Interstitial Brachytherapy
Sources used are in the form of needles, wires, or seeds.
Interstitial afterloading techniques consist of two steps:
• First step consists of inserting unloaded, stainless-steel needles (1-2
cm apart) into the tumour.
• Second step consists of afterloading the unloaded needles with
radioactive seeds or connecting the needles to an afterloading
machine for remotely-controlled source insertion.
 Systems of Interstitial Brachytherapy

Manual methods
 Manchester/Paterson-Parker system
 Quimby system
 Memorial nomographs
 Paris system

Computer methods
 Manchester/P-P system
 Peripheral sources define the target region
 Goal is to optimize dose uniformity
 Radium dosage system to deliver uniform
dose(within +/-10%) to a plane or volume
 Planning relies on pre-calculated tables of the
cumulative source strength per unit dose (in mgh
per 1000 cGy)
 To obtain the total source strength, table value is
multiplied by the desired dose
 Planar Implant
 Reference dose plane is 0.5cm from source plane
 Single plane implant effectively irradiates tissues of
1cm thickness (0.5 cm on either side)
 Dose at 0.5 cm is the minimum dose throughout the
1cm thick slab
Area Fraction of activity on
(cm2) Periphery Area

< 25 2/3 1/3

25-100 1/2 1/2
> 100 1/3 2/3
 Arrangement of needles for planar implants

•The spacing between needles should not exceed 1 cm

•For each uncrossed end, effective area to be reduced by 10%

Examples of three
planar implants
A: Both ends crossed
B: One end uncrossed
C: Both ends
uncrossed
 Paterson-Parker Tables for Planar implant
Treating distance in cm

4 x 4 implant

Mg-hrs for different implant areas

 Multiple planes
 Planes should be parallel to each other
 A two plane implant can satisfactorily treat block of
tissue upto 2.0 or 2.5cm

Double plane implant

 Volume implant
 When lesion to be treated is more than 2.5 cm thick

 Volume implant may be in the form of a sphere, cube

or cylinder

 Total amount of radium is divided into 8 equal parts

and distributed as follows:
Sphere: Shell-6 parts, core-2 parts
Cylinder: Belt-4 parts, core- 2parts, each end- 1 part
Cuboid: Each side 1 part, core – 2 parts
 Volume implant (contd)
 Sources should be spaced evenly
 Separation between two needles
should not be more than 1.0 to 1.5 cm.
 In cylindrical implants the belt should
consist of atleast 8 needles and core of
atleast 4.
 Volume determined by the belt must
be reduced by 7.5% for each open end.
 Quimby System
 Uses sources of uniform linear activity

 Sources distributed uniformly over the area or volume

 Result is non-uniform dose distribution, higher in the central region

 Planar implants-Quimby tables give the [Link] required to deliver 1000R at

the centre of treatment plane, upto 3 cm from implant plane

 For Planar implants, stated dose is the maximum dose in the plane of
treatment

 For Volume implants, stated dose is the minimum dose in the plane of
treatment
 Memorial System
 The Memorial system is an extension of Quimby system

 Based on computer generated dose distributions, tables were

constructed that gave mg-hrs to deliver 1000 at designated points

 These tables use proper exposure rate constants and include

effects of oblique filteration and tissue attenuation

 The Memorial Nomogram was used for manual intra-operative

planning of I-125 implantation
 Paris System
 Developed based on experience with Ir-192 interstitial implants by afterloading
techniques
 Better suited to the characteristics of flexible wire implants than the previous
dosage systems
 Sources should be parallel and straight
 Sources should be of equal length and equally spaced
 Lines must be equidistant
 Linear activity must be identical for all the lines

 BASAL DOSE (BD) forms the basis for dosimetry

 BD – arithmetic mean of the minimal dose rates in the central region of the
implant
 Reference dose rate (RD) equal to 85% of BD and it is the dose rate used for dose
prescription
Reference Dose Rate = 0.85 x BD

Each basal dose rate should be within + 10 % of the mean basal

dose rate for a satisfactory implant

BD = (BD1+BD2+BD3+BD4)/4

Calculation of basal dose rate in planar implants

 (A)

(B)
Calculation of basal dose rate in Squares (A) and triangles (B)
 Computer System
 Similar to Paris and Quimby techniques
 Uniform strength sources placed uniformly (about 1.0
to 1.5 cm, larger spacing for larger implants) covering
the entire tumour volume
 Dose inhomogeinity is accepted in the central part of
target
 Dose specified by isodose surface that just covers the
target or impant volume
 Crossing needles not used; Active length of sources
30-40% larger than target length
 Remote afterloading systems
Remote afterloading machines are used in both interstitial
and intracavitary clinical applications.

Essential components of remote afterloading machines are:

• A safe to house the radioactive source.
• Radioactive sources (single or multiple).
• Remote operating console.
• Source control and drive mechanism.
• Source transfer guide tubes and treatment applicators.
• Treatment planning computer.
 Remote afterloading systems
Three common radionuclide sources used in remote
afterloading machines are: Co-60; Cs-137; Ir-192.
Ir-192 is most widely used because of its medium gamma
ray energy (400 KeV) and its high specific activity. Its
disadvantage is its relatively short half-life (73.8 d).
LDR and HDR remote afterloading systems are used for
intracavitary, interstitial, and intraluminal treatments.
 Remote afterloading systems
Advantages of HDR machines are:
• Optimization of dose distribution.
• Treatment on outpatient basis.
• Elimination of staff radiation exposure.
Disadvantages of HDR systems are:
• Uncertainty in biological effectiveness.
• Potential for accidental high exposures.
• Potential for serious errors.
• Increased staff commitment.
 Permanent prostate implants
Brachytherapy is applied in prostate
treatment:
• As primary treatment using permanent
implantation of short lived radionuclide sources
(such as I-125 or Pd-103) emitting low energy
photons .(30kev)
• As a boost to external beam treatments
delivered in the form of fractionated or single
session treatment using an HDR machine.
 Permanent prostate implants
Choice of radionuclide for prostate implant
Palladium-103, which has a shorter half-life (17 d) than
iodine-125 (60 d) delivers a higher initial dose rate and is
thus useful in treating fast growing high grade tumours.
Recommended total dose to the periphery of the target
volume when brachytherapy implant is the sole treatment
modality is:
• 150 – 160 Gy for iodine-125 seed implants.
• 115 – 120 Gy for palladium-103 seed implants
 Eye plaques

Intraocular melanoma is the most common primary

malignant eye tumour in adults, originating mostly in the
choroid (choroidal melanoma).
Traditional treatment was
enucleation (surgical eye removal).
More recent treatment approaches rely on radiotherapy:
• External beam radiotherapy with high energy x rays or charged
particles.
• Brachytherapy with temporary implants based on radioactive seeds
loaded onto an eye plaque.
 Permanent prostate implants
Brachytherapy treatment
Eye plaque loaded with radioactive
seeds is applied externally
to the scleral (outer) eye surface
over the tumour base.
Radiation with appropriate dose
is intended to eliminate tumour
cells without causing anatomical
or functional damage to normal
ocular tissues.
 Intravascular brachytherapy

• Application of radiation (temporary or permanent implant) proved to

prevent restenosis after treatment of arterial stenosis with
angioplasty and stent

• Sealed sources or liquid–filled ballons as temporary implants and

radioactive stents as permanent implants are used
DOSE DISTRIBUTIONS AROUND SOURCES
AAPM TG 43 algorithm
Dose distributions around sources
AAPM TG 43 algorithm
 Dosimetric Parameters
• Air Kerma Strength Sk is specified in terms of air kerma rate at a point along
the transverse axis of the source in free space.
• The dose rate Constant is defined as the dose rate to the water at a distance
of 1 cm on the transverse axis of a unit air kerma strength source in a water
phantom.
• Geometry factor accounts for the variation of relative dose due to the spatial
distribution of activity within the source, ignoring the photon absorption and
scattering in the source structure
• The radial dose function g(r) accounts for the effects of absorption and
scatter in water along the transverse axis of the source (θ= π/2)
• Anisotrophy factor F(r,θ) accounts for the anisotropy of dose distribution
around the source including the effects of self absorption
 Dose calculation procedures
Manual dose calculations
Pre-calculated dose distributions (atlases)
For some clinical situations, in which the arrangement
of sources for the implant follows a standard pattern,
(linear array, tandem and ovoids, vaginal
Cylinder) pre-calculated dose distributions (atlases) may
be used with appropriate scaling of source strength
(activity).
 Source localization
Source localization can be established by the use of
several radiographic methods:
• Two orthogonal films.
• Two stereo-shift films.
• Computerized tomography (CT) scanning.
 Computerized treatment planning
• Calculated dose values are used to display isodose
surfaces as well as dose-volume histograms.
• Three dimensional displays of dose distributions offer a
major advantage in their ability to help visualize dose
coverage in 3-D, as seen from any arbitrary orientation.
 Optimization of dose distribution

• Optimization of dose distribution is achieved by establishing the

relative spatial or temporal distribution of the sources and by
weighting the strength of the individual sources

• When computer algorithms are not available, optimization is

usually carried out by trial and adjustment.
 Commissioning of brachytherapy TPS

Major sources of errors in brachytherapy are:

• Incorrect source calibration
• Incorrect use of dosimetric quantities and units in the calculation
algorithms.
• It is essential to verify correct labeling of the input and
output quantities and units used in the dose calculation
software.
• Special care must be taken with regard to the specification
of source strength (activity).
 COMMISSIONING OF BRACHYTHERAPY TPSs
Calibration chain
• Well type (re-entrant) chambers must
have a calibration coefficient
traceable to a standards laboratory,
i.e., they must have been calibrated
at a national standards laboratory or
at a secondary standards laboratory.
• For high strength sources, the source
strength (activity) measurements may
also be carried out with calibrated
stem type ionization chambers
 Quality Assurance in Brachytherapy

Regular checks of sources and applicators

Mechanical integrity of a source must be checked at regular
intervals by:
• Visual inspection
• Leak testing
• Activity measurement
Visual inspection and radiographic evaluation of all
applicators should be carried out periodically.
 Quality Assurance in Brachytherapy
Regular checks of sources and
applicators
For short half-life sources, activity to
be measured at the time of receipt
and compared with manufacturer’s
quoted value
For long half-life sources, activity to be
checked at reasonable frequency
For applicators it is necessary to check
that:
• Assembly is structurally sound.
• All clamps, screws and retaining
devices are functioning properly.
 Radiation monitoring around patients
• After a permanent or temporary implantation of
radioactive sources in a patient, a radiation survey must
be carried out in areas within and around the patient and
the patient’s room

• Radiation levels should be measured and recorded to assist

in maintaining minimum exposure to hospital staff and visitors
 QUALITY ASSURANCE IN BRACHYTHERAPY
Radiation monitoring around patients
• Radiation levels in adjoining patients’ rooms should be
low so that no individual will be exposed to an equivalent
dose exceeding 0.2 mSv in any one hour.
• Prior to discharge of an implant patient from hospital the
patient and the patient’s room must be surveyed.
• For patients with temporary implants a survey must be
done upon removal of the sources to confirm complete
removal of all sources.
 Conclusion
• About 10 – 20 % of radiation oncology patients are treated
with brachytherapy; 80 – 90 % are treated with external
beam techniques
• Basic principles of brachytherapy have not changed much
during the past 100 years of radiotherapy
• In comparison to manual loading, remote afterloading has
made brachytherapy much more efficient for the patient
and safer for staff from the radiation protection point of
view.