Discuss the Leipzig cone or Valencia applicator.

The Leipzig cone brachytherapy applicator is a tungsten, cup-shaped applicator that

holds the source at the apex of the dome. These were originally designed for
Iridium-192 (192Ir) HDR brachytherapy treatments. They are available in many sizes
from approximately 10 mm up to diameter in the range of 30-45mm. This is important to
choose the right size for the CTV and to provide additional margin for the PTV. The
Leipzig applicator also comes with a plastic cap that must be used over the opening of
the applicator during treatment. This ensures electronic equilibrium and filters
secondary electrons from exiting the applicator. One study showed that the failure to
include this plastic cap will lead to an increased dose to the first 1 mm of skin up to
1500 percent. While electron beams from linear accelerators are the preferred treatment
modality for superficial lesions, due to their uniform dose distribution, rapid dose falloff,
and fast treatment times, there are circumstances that prevent the large and bulky
electron cone from being used. Some locations where the Leipzig applicator may be
preferred to a LINAC include tumors of the skin, face, mouth, tongue, and external
genitalia. The Leipzig applicator excels in this area, filling the gap left by the
shortcomings of the linear accelerator. There are two major disadvantages of the
Leipzig applicator. It is reliant on a live source with varying activity levels. This means
that the treatment times can exceed 20 minutes in some cases. The typical treatment
regimen for this HDR Brachytherapy 5 to 10 Gy, twice per week, with a total dose of 30
to 40 Gy. With a low activity source, the dose rate can be less than 50cGy per minute
leading to long treatment times. The second disadvantage of the Leipzig applicator is
the fact that it does not have a flattening filter. This non-flat dose distribution leads to a
more pointed, forward-facing, isodose curve and an inhomogeneous dose to the
CTV.However, for small, deeper seated tumors, this can be a benefit over the Valencia
Applicator, since the lack of flattening filter allows for deeper penetration. The Valencia
HDR applicator was developed from the Leipzig applicator, with the addition of a
flattening filter. Included below are some examples of what the Leipzig applicator looks
like and how it can be used.
References

1. Niu H, Hsi WC, Chu JC, Kirk MC, Kouwenhoven E. Dosimetric characteristics of
the Leipzig surface applicators used in the high dose rate brachy radiotherapy.
Med Phys. 2004;31(12):3372-3377. doi:10.1118/1.1812609
2. Hwang I-M, Lin S-Y, Lin L-C, Chuang K-S, Ding H-J. Alternative effective modality
of Leipzig applicator with an electron beam for the treatment of superficial
malignancies. Nuclear Instruments and Methods in Physics Research Section A:
Accelerators, Spectrometers, Detectors and Associated Equipment.
2003;508(3):460-466. doi:10.1016/s0168-9002(03)01664-4

3. Guinot JL, Rembielak A, Perez-Calatayud J, et al. GEC-Estro acrop

recommendations in skin brachytherapy. Radiotherapy and Oncology.
2018;126(3):377-385. doi:10.1016/j.radonc.2018.01.013

4. Granero D, Candela-Juan C, Vijande J, et al. Technical Note: Dosimetry of Leipzig

and Valencia applicators without the plastic cap. Med Phys. 2016;43(5):2087.
doi:10.1118/1.4944784