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ICRU REPORT 38
 ICRU REPORT 38

Dose and Volume

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Specification for
Reporting Intracavitary
Therapy in Gynecology

Issued: 1 March 1985

First Reprinting December 15,1991

INTERNATIONAL COMMISSION ON RADIATION

UNITS AND MEASUREMENTS

7910 WOODMONT AVENUE

BETHESDA, MARYLAND 20814

U.S.A.
 THE INTERNATIONAL COMMISSION
ON RADIATION UNITS AND MEASUREMENTS
INDIVIDUALS PARiflCIPATING IN THE PREPARATION OF THIS REPORT

Commission Membership During Preparation of Commission Sponsor

This Report
A. W AMBERSIE
H. O. WYCKOFF, Chairman Universite Catholique de Louvain
A. ALLISY, Vice Chairman Bruxelles, Belgium
R. S. CASWELL, Secretary
G.E.D.ADAMS
G. COWPER
P.EDHOLM
J. R. GREENING Report Committee
D.HARDER D. CHASSAGNE. Co-Chairman
A. M. KELLERER Institut Gustave Roussy
H. H. ROSSI Villejuif, France

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W. K. SINCLAIR A. DUTREIX, Co-Chairman
J. VAN DER SCHOOT Institut Gustave Roussy
A. W AMBERSIE Villejuif, France
L. S. TAYLOR, Honorary Member and Member
P.ALMOND
Emeritus M. D. Anderson Hospital and Tumor Institute
Houston, Texas, U.S.A.
Current Commission Membership J. M. V. BURGERS
Antoni van Leeuwenhoek Ziekenhuis
H. O. WYCKOFF, Chairman Amsterdam, The Netherlands
A. ALLISY, Vice Chairman M.BuSCH
R. S. CASWELL, Secretary Strahlenklinik der Gesamthochschule
G.E.D.ADAMS Essen, Germany
G.COWPER C. A. JOSLIN
L. FEINENDEGEN Cookridge Hospital
I. ISHERWOOD Leeds, United Kingdom
A. M. KELLERER
J. R. MALLARD
H. H. ROSSI
W. K. SINCLAIR
J. VAN DER SCHOOT Consultants to the Report Committee
A. WAMBERSIE M.COHEN
L. S. TAYLOR, Honorary Chairman and Member McGill University
Emeritus Royal Victoria Hospital
Montreal, Canada
Executive Secretary T.LANDBERG
Malmo Allmiinna Sjukhus
W.R.NEY Malmo, Sweden

The Commission wishes to express its appreciation to the individuals involved in the preparation of this report
for the time and effort they devoted to this task and to express its appreciation to the organizations with which they
are affiliated.

Copyright © International Commission on Radiation Units and Measurements 1985

(For detailed information on the availability of this and other ICRU Reports, see page 20)
 Preface
Scope of ICRU Activities
The International Commission on Radiation Units
and Measurements (ICRU), since its inception in 1925,
has had as its principal objective the development of
internationally acceptable recommendations re-
garding:
(1) Quantities and units of radiation and radioac-
tivity,
(2) Procedures suitable for the measurement and
application of these quantities in clinical radiology and
radiobiology,
(3) Physical data needed in the application of these
procedures, the use of which tends to assUre uniformity
in reporting.
The Commission also considers and makes similar
types of recommendations for the radiation protection
field. In this connection, its work is carried out in close
cooperation with the International Commission on
Radiological Protection (ICRP).
Policy
The ICRU endeavors to collect and evaluate the latest
data and information pertinent to the problems of ra-
diation measurement and dosimetry and to recommend
the most acceptable values and techniques for current
use.
The Commission's recommendations are kept under
continual review in order to keep abreast of the rapidly
expanding uses of radiation.
The ICRU feels it is the responsibility of national
organizations to introduce their own detailed technical
procedures for the development and maintenance of
standards. However, it urges that all countries adhere
as closely as possible to the internationally recom-
mended basic concepts of radiation quantities and
units.
The Commission feels that its responsibility lies in
developing a system of quantities and units having the
widest possible range of applicability. Situations may
arise from time to time when an expedient solution of
a current problem may seem advisable. Generally
speaking, however, the Commission feels that action
based on expediency is inadvisable from a long-term
viewpoint; it endeavors to base its decisions on the
long-range advantages to be expected.
The ICRU invites and welcomes constructive com-
ments and suggestions regarding its recommendations
and reports. These may be transmitted to the
Chairman.
Current Program
The Commission has divided its field of interest into
twelve technical areas and has assigned one or more
members of the Commission the responsibility for
identification of potential topics for new ICRU activities
in each area. A body of consultants has been constituted
for each technical area to advise the Commission on the
need for ICRU recommendations relating to the tech-
nical area and on the means for meeting an identified
need. Each area is reviewed periodically by its sponsors
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and consultants. Recommendations of such groups for
new reports are then reviewed by the Commission and
a priority assigned.
The technical areas are:
Radiation Therapy
Diagnostic Radiology
Nuclear Medicine
Radiobiology
Radioactivity
Radiation Physics-X Rays, Gamma Rays and Electrons
Radiation Physics-Neutrons and Heavy Particles
Radiation Protection
Radiation Chemistry
Critical Data
Theoretical Aspects
Quantities and Units
The actual preparation of ICRU reports is carried
out by ICRU report committees. One or more Com-
mission members serve as sponsors to each committee
and provide close liaison with the Commission. The
currently active report committees are:
Absolute and Relative Dosimetry at High Doses
Characterization of Irradiation for Materials-Effect Studies
Chemical Dosimetry
Clinical Dosimetry for Neutrons
Computer Uses in Radiotherapy
Definitions and Terminology for Computed Tomography
Definitions of Physical Parameters to Specify Performance of
Imaging Instruments
Determination of Absorbed Dose Distribution Around a Source
Used for Interstitial Therapy
Dose Specifications for Reporting Interstitial Therapy
Measurement of Dose Equivalent
Modulation Transfer Function for Screen-Film Systems
Practical Determination of Dose Equivalent Index
Quality Assurance in External Beam Therapy
Stopping Power
Tissue Equivalent Materials
ICRU Reports
In 1962 the ICRU, in recognition of the fact that its
triennial reports were becoming too extensive and in
Iv ... Preface
some cases too specialized to justify single-volume
publication, initiated the publication of a series of re-
ports, each dealing with a limited range of topics. This
series was initiated with the publication of six re-
ports:
ICRU Report lOa, Radiation Quantities and Units
ICRU Report lOb, Physical Aspects of Irradiation
ICRU Report lOc, Radioactivity
ICRU Report 10d, Clinical Dosimetry
ICRU Report lOe, Radiobiological Dosimetry
ICRU Report 10f, Methods of Evaluating Radiological Equip-
ment and Materials
These reports were published, as had been many of
the previous reports of the Commission, by the United
States Government Printing Office as Handbooks of the
National Bureau of Standards.
In 1967, the Commission determined that in the fu-
ture the recommendations formulated by the ICRU
would be published by the Commission itself. This re-
port is published by the ICRU pursuant to this policy.
With the exception of ICRU Reports lOa, lOd, and lOe,
the other reports of the "10" series have continuing
validity and, since no subsequent reports were designed
specifically to supersede them, they will remain avail-
able until the material is essentially obsolete. All future
reports ofthe Commission, however, will be published
under the ICRU's own auspices. Information about the
availability of ICRU Reports is given on page 20.
ICRU's Relationships With Other Organizations
In addition to its close relationship with the Inter-
national Commission on Radiological Protection, the
ICRU has developed relationships with other organi-
zations interested in the problems of radiation quan-
tities, units and measurements. Since 1955, the ICRU
has had an official relationship with the World Health
Organization (WHO) whereby the ICRU is looked to for
primary guidance in matters of radiation units and
measurements and, in turn, the WHO assists in the
world-wide dissemination of the Commission's recom-
mendations. In 1960, the ICRU entered into consulta-
tive status with the International Atomic Energy
Agency. The Commission has a formal relationship with
the United Nations Scientific Committee on the Effects
of Atomic Radiation (UNSCEAR), whereby ICRU ob-
servers are invited to attend UNSCEAR meetings. The
Commission and the International Organization for
Standardization (ISO) informally exchange notifica-
tions of meetings and the ICRU is formally designated
for liaison with two of the ISO Technical Committees.
The ICRU also corresponds and exchanges fmal reports
with the following organizations:
Bureau International de Metrologie Legale
Bureau International des Poids et Mesures
Commission of the European Communities
Council for International Organizations of Medical Sciences
Food and Agriculture Organization of the United Nations
International Council of Scientific Unions
International Electrotechnical Commission
International Labor Office
International Organization for Medical Physics
International Radiation Protection Association
International Union of Pure and Applied Physics
United Nations Educational, Scientific and Cultural Organiza-
tion
The Commission has found its relationship with all
of these organizations fruitful and of substantial benefit
to the ICRU program. Relations with these other in-
ternational bodies do not affect the basic affiliation of
the ICRU with the International Society of Radi-
ology.
Operating Funds
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In the early days of its existence, the ICRU operated
essentially on a voluntary basis, with the travel and
operating costs being borne by the parent organizations
of the participants. (Only token assistance was originally
available from the International Society of Radiology.)
Recognizing the impracticability of continuing this
mode of operation on an indefinite basis, operating
funds were sought from various sources.
Financial support has been received from the fol-
lowing organizations:
ADAC Laboratories
Agfa-Gavaert, N.V.
Atomic Energy Control Board
B.A.T. Cigaretten Fabriken GMBH
Central Electricity Generating Board
CGR Medical Corporation
Commission of the European Communities
Council for International Organizations of Medical Sciences
Danish Scientific Fund
Dutch Society for Radiodiagnostics
Eastman Kodak Company
E.l. du Pont de Nemours and Company
Ford Foundation
Fuji Photo Company
General Electric Company
Gilbert X-ray Company
Hitachi Medic
International Atomic Energy Agency
International Radiation Protection Association
International Society of Radiology
Italian Radiological Association
Japan Industries Association of Radiation Apparatus
John och Augusta Perssons stiftelse
Konishi-Roku Photo Company
National Cancer Institute of the U.S. Department of Health and
Human Services
N.V. Philips Gloeilampenfabrieken
Philips Medical Systems, Incorporated
Picker Corporation
Pyne Corporation
Radiological Society of North America
Rockefeller Foundation
Shimadzu Corporation
Siemens Aktiengesellschaft
 Preface . •• V

Society of Nuclear Medicine ipating in ICRU activities, (2) travel costs involved in
Statens laegevidenskabelige Forskningsrad ICRU meetings, and (3) meeting facilities and ser-
Toshiba Corporation
United Nations
vices.
U.S. Bureau of Radiological Health of the Food and Drug Admin- In recognition of the fact that its work is made pos-
istration sible by the generous support provided by all of the or-
World Health Organization ganizations supporting its program, the Commission
Xerox Corporation expresses its deep appreciation.
In addition to the direct monetary support provid-
ed by these organizations, many organizations provide HAROLD O. WYCKOFF
indirect support for the Commission's program. This Chairman, ICRU
support is provided in many forms, including, among Bethesda, Maryland, U.S.A.
others, subsidies for (1) the time of individuals partic- 15 January 1985

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 Contents
Preface .................................................... iii
1. Introduction............................................. 1
2. Definition of Terms and Concepts Currently Used in
Intracavitary Therapy ................................... 4
2.1 Treatment Techniques. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1.1 Radium Substitutes ........................... . ..... 4
2.1.2 Simulation of Linear Sources ......................... 4
2.1.3 Dose Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1.4 Afterloading Techniques ............................. 5
2.2 Absorbed-Dose Pattern and Volumes. . . . . . . . . . . . . . . . . . . . . . 5

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2.2.1 Absorbed-Dose Pattern .............................. 5
2.2.2 Volumes ............... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.3 Specification of Radioactive Sources ...................... 8
3. Recommendations for Reporting Absorbed Doses and
Volumes in Intracavitary Therapy. . . . . . . . . . . . . . . .. . . . . . . . . 9
3.1 Introduction ........ . ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.2 Description of the Technique ........... . ................ 9
3.2.1 The Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.2.2 Simulation of Linear Sources .. . ...................... 9
3.2.3 The Applicator ..................................... 9
3.3 Recommendations for Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.3.1 Total Reference Air Kerma . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.3.2 Description of the Reference Volume .................. 10
3.3.3 Absorbed Dose at Reference Points .................... 11
3.3.4 Calculation of Dose Distribution ...................... 12
3.4 Definition of the 60 Gy Reference Volume in
Special Situations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.4.1 One Linear Source Only ........................... . . 14
3.4.2 Vaginal Sources Only. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 14
3.4.3 Rigid Applicator .................................... 14
3.4.4 Uterine Packing (In Endometrial Cancer) .............. 14
4. Time-Dose Pattern .......... . ......... . . . . . . . . . . . . . . . . . . . 15
4.1 Radiobiological Considerations ........................... 15
4.2 Recommendations for Reporting Time-Dose Pattern ........ 15
5. Conclusions and Final Recommendations .................. 16
Appendix
Specification of Radioactive Sources Used in
Intracavitary Therapy .... . ............................... 17
References.. ... . .. .. ... .. .. . .. . . .. . .. . .. .. . .. ...... .. . .. .. . 18
ICRU Reports ........................... . . . . . . . . . . . . . . . . . . . 20
Index...................................................... 23
 Dose and Volume Specification
for Reporting Intracavitary
Therapy in Gynecology
1.
In 1978, the ICRU published Report 29, Dose Spec-
ification for Reporting External Beam Therapy with
Photons and Electrons (ICRU, 1978). The present re-
port deals with the problem of dose and volume speci-
fication for reporting intracavitary therapy. The prin-
cipal subject is dose and volume specification for the
intracavitary treatment of cervix carcinoma. However,
the concepts developed in this report are designed to be
applicable to other types of intracavitary applications,
such as uterine body, etc.
Intracavitary therapy is often used in combination
with external beam therapy and, therefore, the same
terminology and definitions of terms are advocated. In
particular, it would be desirable, whenever possible, to
use the concepts of target volume, treatment volume
and irradiated volume, as defined for external beam
therapy. However, due to the high dose-gradient around
the sources (throughout the tumor and target volume),
the specification of the target absorbed dose in terms
of the dose absorbed either at one or several reference
point(s) within the target volume is not considered
meaningful; therefore, the approach used in external
beam therapy cannot be used.
The problem of dose specification is still more com-
plicated when two or more target volumes are identified,
some being treated either by external, or by intracavi-
tary therapy and some by both methods. Furthermore,
attention should be paid to the different time-dose
patterns linked to each treatment method.
Based on clinical experience, different systems have
been proposed for the treatment of cervix carcinoma.
Three basic systems have been developed: the Stock-
holm system (Kottmeier, 1964)1, the Paris system
(Lamarque and Coliez, 1951)1 and the Manchester
1The references quoted are not the first references but those which
seem to be the most comprehensive.
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Introduction
system (Paterson, 1948)1. Most of the systems used
throughout the world are derived from these three basic
systems.
As used here, the term "system" denotes a set of rules
taking into account the source strengths, geometry and
method of application in order to obtain suitable dose
distributions over the volume(s) to be treated. For re-
porting, the system includes recommendations for
specifying the application and possibly, as in the
Manchester system, for calculating the dose rate (or
dose) at specific points.
Typical applications according to the Stockholm
system and the historical Paris system are presented in
Figures 1.1 and 1.2, respectively. In both systems, ap-
plications have been reported in terms of "mg.h" (mil-
ligram hours), i.e., the product of the total mass or ra-
dium contained in the sources (in mg) and of the dura-
tion of the application (in hours).
The Manchester system (Paterson and Parker, 1934),
derived from the original Paris system, initiated about
1920, was designed to deliver a constant dose rate to
defmed points near the cervix, irrespective of variation
in size and shape of the uterus and vagina. In the
Manchester system, an application was specified in
terms of the "dose" in roentgens delivered at specific
points such as points "A" and "B" (Figure 1.3). Points
A and B are still widely used throughout the world, al-
though their exact meaning and their definition have
not always been interpreted in the same way in different
centers and even in a given center over a period of time.
In particular, some centers relate point A to anatomical
references in the patient, others to the geometry of the
sources.
The different methods of definition provide different
values for the calculated dose rate to point A. As a result,
where a prescribed dose to point A is used to calculate
the total time for an insertion, different values of time
1
2 • • . 1. Introduction

Fig. 1.1. The Stockholm system. Typical treatment of a cervix

carcinoma with a radium application (uterus normal in size and
shape). The intrauterine rod-shaped applicator is loaded with 53-88
mg radium (74 mg in the example shown). The vaginal applicator
usually consists of a flat box containing 60-80 mg radium (70 mg in
the example shown), but in special cases other forms of vaginal ap-
plicators may be used. Classically, the two applicators are not fixed
to each other, but fixed or semi-fixed combinations have been de-
veloped. The vaginal applicator is held against the cervix and lateral
fornices by careful and systematic gauze packing. Typically, 2 or 3
applications are given with 3-week intervals, each application lasting
for 27-30 hours. Modifications of the Stockholm method, using larger
amounts of radium, allow for application times of 10-18 hours at each
treatment. The figure shows a typical application and the amount of
radium in the two applicators as well as the dose-rate (Figure from
~
o Scm Walstam, 1954).

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Fig_ 1.2. The historical Paris system. Typical radium application
for a treatment of cervix carcinoma consisting of: 3 individualized
vaginal sources (one in each lateral fornix and one central in front of
the cervical os), 1 intrauterine source made of 3 radium tubes (in so-
called tandem position). Possible variations of the Paris system in-
clude: 2 vaginal sources (or only one) in case of a narrow vaginal cavity;
only 2 intrauterine radium tubes (or only one) in case of short uterus.
The active length of the sources is usually 16 mm, their linear activity
being between 6 and 10 mg per cm, and their strength between 10 and
15 mg of radium. The total activity used is one of the lowest in use for
such treatments and implies a typical duration of the application of
6-8 days. Typically, the ratio of the total activity of the vaginal sources
to the total activity of the uterine sources should be 1 (with variations
between 0.66 and 1.5). As far as the method of application is con-
cerned, the historical Paris system does not imply any fixed distance
between the vaginal sources, nor connection between vaginal and
uterine sources (Pierquin, 1964).

B B
•
Fig. 1.3. The Manchester system. Definition of points" A" and "B".
In the classical Manchester system, point A is dermed as a point 2 em
lateral to the central canal of the uterus and 2 em up from the mucous
mem brane of the lateral fornix, in the axis of the uterus. Point B is
defined as being in the transverse axis through points A, 5 cm from
the midline. In clinical practice, dose calculations are often made from
radiographs and point A is taken 2 em up from the flange of the in-
trauterine source and 2 em lateral from the central canal as indicated
in the figure (Meredith, 1967). In a typical application, the loading of
intrauterine applicators varied between 20 and 35 mg of radium and
between 15 and 25 mg of radium for each vaginal ovoid. The resultant
treatment time to get 8000 R at point A was 140 hours.

will be obtained, depending on the method used. It is
therefore important to give a precise description of the
method used to calculate the dose rate at specific
points.
On the other hand, the Manchester system is based
on a set of strict rules concerning the method of insert-
ing the radium sources (in particular the choice of vag-
inal ovoids and their separation, and the relative
strengths ofthe intrauterine and intravaginal sources).
Assuming that the Manchester definition of point A is
used, this will be the location where there is least vari-
ation in the dose rate from one source arrangement to
another one.
It is opportune now to reconsider dose and volume
specification for several reasons:
1. Introduction... 3
(i) radium is being progressively replaced by gamma-
ray emitting substitutes (137CS, 192Ir and 60CO)2;
(ii) new sets of sources are available, for which the old
systems are not always suitable;
(iii) SI units are now being widely used in the field of
radiology; and
(iv) computers are routinely used for calculations and
complete sets of intracavitary dose distribution
in several planes are now becoming available, from
which new information and relationships can be
derived.
2 Californium-252, a neutron emitter, is also used but will not be
discussed in this document.
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 2. Definition of Terms and Concepts Currently Used in Intracavitary Therapy
2.1 Treatment Techniques
2.1.1 Radium Substitutes
When radium was the only available radionuclide, the
characteristics of the sources used for intracavitary
applications were similar and their activities were of the
same order of magnitude. Typically, the elementary
radium tubes most frequently used were 1.5 to 2.2 cm
long, with source strengths ranging from 5 to 20 mg of
radium and a total Pt filtration of 1 to 2 mm (see Ap-
pendix).
The replacement of radium by 137Cs, 192Ir and 60CO
may be accomplished according to two options. In the
first option, the new sources (mainly 137CS) are similar
in size and shape and have an output similar to radium
sources. The same technique of application can then be
applied and the clinical experience gained with radium
remains fully relevant. The principal advantages of the
replacement of the radium concern radiation protection'
these include no contamination from leakage and les~
shielding in the case of 137CS and 192Ir.
The second option takes advantage of the improved
technology in the preparation of the sources, the in-
creased specific activities available with artificial ra-
dionuclides and the technical possibility of making
miniaturized sources. These new types of source are
designed to allow the use of new and better techniques
of application, for instance, afterloading, and to improve
the dose distribution by providing, for instance, greater
flexibility in the selection of the relative source activi-
ties, source lengths or both.
In addition, the large range of source activities at
present available allows the therapist to modify com-
pletely the time-dose pattern of application. Irradiation
times ranging from 6 to 8 days, with radium in the Paris
system, could be reduced to a few minutes (O'Connell
et al., 1967). Thus, continuous low dose-rate irradiation
can be replaced by fractionated high dose-rate irra-
diation. It should be stressed that such drastic changes
in the time-dose pattern require a modification of the
total dose and that the clinical experience accumulated
over many decades with relatively low dose-rate radium
applications can no longer be applied without careful
evaluation, not only as far as normal tissue tolerance is
concerned, but also for effects on the tumor.
2.1.2 Simulation of Linear Sources
In many of the modern application devices, linear
sources are simulated by a set of point sources. These
point sources may be of equal activity and equally
spaced, thus simulating a uniform linear activity. In
other applications, more complex arrangements are
4
used, involving different activities or different spacing
in order to modify and improve the shape of the relevant
isodose surfaces (Cardis and Kjellman, 1967; Chassagne
et al., 1969; Bjornsson, 1980; Van der Laarse, 1981).
In the simple case where a linear source is simulated
by a series of regularly spaced point sources of equal
activity, each point source is equivalent to a given length
of the linear source. The linear source simulated by the
point sources is longer than the distance between the
extreme point sources (see Figure 2.1). At distances
larger than half the spacing between the point sources,
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the dose distribution around the point sources is similar
to that around a linear source of the same total activity
(Dutreix and Wambersie, 1968).
Linear sources can also be simulated by moving point
sources of appropriate activity. Variations of the type
of movement, continuous or stepwise, of the speed and
dwell times of the source at different positions, will
modify the shape of the isodose surfaces (Henschke et
al., 1966; Joslin et al., 1969; Twiss and Bradshaw, 1970;
Busch, 1973; Busch et al., 1977; Himmelmann et al.,
1980; Von Essen, 1980).
2.1.3 Dose Rates
In conventional brachytherapy with radium tubes,
the dose rate at the point or surface where the dose is
prescribed, lies between 0.4 and 2 grays per hour. It is
common practice to refer to this type of treatment as
low dose-rate brachytherapy.
The introduction of remote afterloading devices into
clinical medicine (see Section 2.1.4. below) has pre-
!-E=lcm-!
• • ::;VI
r
,,--=--=='-<:':-::-~--=-">'-'=:--=--
~
I
<--
5
- - -' /
I
E'l
u
Ii I, " ' " ,,, I
o 2 3 4cm
Fig. 2.1. Comparison of dose distributions between "n" small
sources of activity ao spaced by a distance E, and a linear source of
length I = nE and of total activity a = nao. The curves are labeled 5,
2, 1 for relative dose rate. The dotted lines result from a series of point
sources and the full lines from a linear source. The dose is not cor-
rected for oblique filtration (Dutreix and Wambersie, 1968).

sented an opportunity for investigating different dose
rates and, in particular, very high dose rates. In this
Report, the term high dose rate refers to any dose rate
higher than 0.2 gray per minute (12 grays per hour),
although it usually refers to dose rates as high as 2 to 5
grays per minute, i.e., treatment sessions of a few min-
utes duration.
Some radiotherapists are now exploring intermediate
dose rates, between 2 and 12 grays per hour and we
propose to refer to such dose rates as medium dose
rates.
Such definitions of low dose rate, medium dose rate
and high dose rate are arbitrary and debatable. In this
connection, it must be stressed that the treatment du-
ration should always be clearly reported (see Section
4).
2.1.4 Afterloading Techniques
Modifications of application techniques in intra-
cavitary therapy are often made for purposes of radia-
tion protection. As already discussed, some advantage
is obtained by replacing radium by ')I-emitters of lower
energy (the shielding problems are easier and the risk
of contamination is also avoided). However, the main
improvement in radiation protection derives from the
introduction of afterloading techniques.
In afterloading techniques, unloaded applicators or
guides are introduced into the patient cavities, ac-
cording to a chosen plan and without exposure of the
staff. The treatment sources are inserted later, after the
position of the applicators has been radiographically
checked using dummy sources. The dose distribution
can also be computed so that the position of the guides
can be corrected if necessary before the sources are in-
serted.
Afterloading techniques help to ensure the correct
and safe positioning of the radioactive sources in the
patient, in addition to facilitating the transfer of the
sources to and from a shielded storage container. Af-
terloading techniques may be manual or remotely
controlled.
In remotely controlled afterloading techniques,
source insertion and removal are operated from a con-
trol panel distant from the patient, thus eliminating
exposure of the clinical staff. With some of the more
advanced devices, the sources are automatically re-
tracted into the storage container when the door of the
patient's room is opened. While either manual or me-
chanical afterloading techniques may be used for low
dose-rate applications, remote afterloading techniques
are mandatory for medium and high dose-rate appli-
cations in order to ensure good radiation protection of
the staff.
Afterloading is an important aspect of intracavitary
therapy. Moreover, as more centers are now adopting
2.2 Absorbed-Dose Pattern and Volumes • •• 5
afterloading techniques as well as modifying their ir-
radiation procedures, attention needs to be given to the
problems of dose specification and dose-time relation-
ships. As already stressed, the clinical experience ac-
cumulated with radium techniques cannot be applied
to new irradiation conditi{)ns without careful consid-
eration.
2.2 Absorbed-Dose Pattern and Volumes
2.2.1 Absorbed-Dose Pattern
The pattern of the absorbed dose to the soft tissue in
intracavitary therapy differs from the dose pattern
encountered in external therapy. In external beam
therapy, one aim is to reduce variations in dose over the
target volume. In general, variations greater than ±10%
Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016
are not deemed acceptable. Outside the treatment
volume the dose falls off more or less steeply. For ex-
ample, pelvic irradiation with a 60Co "box technique"
(see Figure 2.2a) produces a dose distribution within the
treatment volume which is rather flat; the dose falls off
rapidly at the edges of the treatment volume and in the
lateral directions (Fields 3 and 4) remains fairly con-
stant at about 30% of the dose at the center of the
treatment volume. With intracavitary therapy, the dose
is maximum adjacent to the sources and at the center
of the treated volume, and it falls off continuously with
distance from the sources. Consequently, the size of the
treatment volume cannot be deduced from a simple
inspection of the isodose pattern. Therefore, the ra-
diotherapist has to indicate which dose level defines the
treatment volume. In Figure 2.2c, the absorbed dose has
been arbitrarily normalized to 100% at a distance of 2
cm from the uterine axis in order to allow a comparison
of the absorbed dose patterns. Although the dose gra-
dient (dose change per unit distance) at the border of
the treatment volume is similar for either technique, as
shown in Figure 2.2c, the dose patterns differ substan-
tially within the treatment volume as well as in healthy
tissues distant from the treated region.
2.2.2 Volumes
The definitions given in ICRU Report 29 for external
beam therapy will be modified where necessary for in-
tracavitary therapy situations.
Target Volume
The target volume contains those tissues that are to
be irradiated to a specified absorbed dose according to
a specified time-dose pattern. For curative treatment,
the target volume consists of the demonstrated tu-
mor(s), if present, and any other tissue with presumed
tumor.
For any given situation, there may be more than one
target volume. This is particularly the case for treat-
 Ox

Field No Size Weighting

(cm x cm) factors
17 x 20 37 "/.
2 17 x 20 37 "/.
3 10 x 20 13 "/.
L. 10 x 20 13 "/.
3

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oI , , ,
5, 10cm
, ,
2-
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2.2a

'/
; --- .....
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,
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I I , \
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I I \ \ \ \

A ...j....£_I_.l--->.
1110\\\ \ \
7050 30 20
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\ \\ . . . - - _
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10 cGy,h- 1
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\ ,
' ......... ",'
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..... "
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_",,/ I I I
____ - .... ",I' /1
/

---
--- -
..,'"
-"
/

/
/
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, _------/
.....

-----IRIDIUM WIRES
/
-" '"

RADIUM TUBES
uterine tubes 3 x 10 mg (same reference air kerma
rates as radium tubes )
vaginal tubes 2 x 15 mg
filtration 1 mm Pt correction made for oblique
fill ration
2.2b
 2.2 Absorbed-Dose Pattern and Volumes . . . 7

1//'
I
I//l
100
I~I
l;/j
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a.
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o 3
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o
-'0 -5 +5 +10 em

2.2c
Fig. 2.2. Comparison of absorbed dose patterns between external and intracavitary therapy. 2.28 shows the dose distribution for an irradiation
of the pelvis with a 6OCO teletherapy machine and four fields-the so-called "box technique" (see ICRU Report 29, Figure 3.4). The border of
the target area is indicated by the heavy dotted line. 2.2b shows a typical dose distribution in an intracavitary application (IAEA, 1972; Dutreix
et al., 1982). 2.2c shows the dose variation along a lateral axis. The full line refers to external therapy (Figure 2.2a, along the beam axis 3 and
4). The dotted line refers to intracavitary therapy (Figure 2.2b, along the AB axis). The absorbed dose has been normalized to 1000/0 at a distance
of 2 cm from the uterine axis. The shaded areas (2 cm wide) show the high dose-gradient regions beyond the border of each of the two treatment
volumes.

ment of cervix carcinoma where, depending on the ex-
tent of disease, some target volumes may be treated
partly or totally by an intracavitary application, while
others are treated mainly by external therapy, The
target volume(s) must always be described, indepen-
dently of the dose distribution, in terms of the patient's
anatomy, topography and tumor volume, For the pur-
pose of reporting intracavitary treatment, that part of
the target volume which has to be irradiated by means
of intracavitary application should be separately de-
scribed, It should also be stated whether this volume will
receive treatment only by intracavitary application or
will receive treatment by both modalities. The physical
dimensions of the target volume must be given. Exam-
ples illustrating target volumes in patients with carci-
noma of the cervix are given in Figure 2.3.
Treatment Volume
The treatment volume is defined as the volume en-
closed by a relevant isodose surface selected by the ra-
diotherapist, and encompasses at least the target vol-
ume. In intracavitary therapy, it is not feasible to ex-
press the value of the isodose surface enclosing the
treatment volume as a percentage of the dose at any
point within the treatment volume. This is because of
the steep dose gradient around the sources and the
variation encountered in the techniques used. It is
necessary to plan the treatment to include the target
volume within the treatment volume.
Reference Volume
The reference volume is defined as the volume en-
closed by the reference isodose surface. In order to fa-
cilitate intercomparisons between radiotherapy centers,
it is necessary to agree upon a reference dose level. The
treatment dose level defining the treatment volume may
be equal to or different from this reference dose level.
For reporting intracavitary therapy, it is necessary to
determine the dimensions of the reference volume.
Irradiated Volume
The irradiated volume is that volume, larger than the
treatment volume, which receives an absorbed dose
8 ... 2. Definition of Terms and Concepts Currenlly Used in Intracavlly Therapy

A. ONLY INTRACAVITARY TREATMENT B. COMBINED INTRACAVITARY AND

EXTERNAL BEAM THERAPY

Targllt lIOIumll of intra- Trutnwnt volumll of

Targllt 'w'Olumll Trcatmlznt volumll cavitary trutmcnt in tracavilary trut mllnt
(cllrvix rllgion + corpus)

\
·• .J

Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016

·!./ \
II
.,,. \
Fillid i\ ;,/. ._./ /
~\~::':'~~0~" -_ .. - .. -~.---- -1
Targllt volumll of Trllatmllnt volume of
utllrnal bum utllrnal bum thllrapy
thuapy

Fig. 2.3. Treatment of cervix carcinoma. Stage II.b. Examples of target volumes and treatment volumes. A-Tumor volume (hatched): 4 cm
X 3 cm X 2 em. The almost pear-shaped target volume includes the entirety of palpable and visible tumor as well as the whole uterus. The planned.
pear-shaped treatment volume encompasses the target volume. Additional methods such as combined surgery or combined external radiation
may be used. B-Tumor volume (hatched): 9 cm X 5 cm X 4 cm. The target volume for brachytherapy will only include the major parts of the
tumor volume. but will include the whole uterus. To treat the rest of the tumor volume and further subclinical disease throughout the pelvis
and the regional lymphatics. external beam therapy will be used. and brachytherapy will be used as boost therapy.

considered to be significant in relation to tissue toler- 2.3 Specification of Radioactive Sources

ance. The significant absorbed dose level can be ex-
pressed as a percentage (e.g., 50%) of the agreed dose
level (see Section 3.3.2.a).
Organs at Risk
Organs at risk are those radiosensitive organs in or
near the target volume which would influence treatment
planning and/or the prescribed dose. For example, in
an intracavitary application for cervix carcinoma, the
main organs at risk are rectum, bladder, ureters and
possibly sigmoid colon.
It is recommended that radioactive sources be spec-
ified in terms of "reference air kerma rate". The ref-
erence air kerma rate of a source is the kerma rate to air,
in air, at a reference distance of 1 meter, corrected for
air attenuation and scattering. For this purpose this
quantity is expressed in J.LGy·h- 1 at one metre.
The total reference air kerma is the sum of the
products of the reference air kerma rate and the dura-
tion of the application for each source.
 3. Recommendations for Reporting Absorbed Doses and Volumes in Intracavitary
Therapy
3.1 Introduction
As the absorbed dose to soft tissue from intracavitary
applications is so highly nonuniform throughout the
target volume, the concepts of maximum, mean, median
and modal target absorbed dose, as defined in ICRU
Report 29 (ICRU 1978), are not relevant. The minimum
target absorbed dose is the only useful concept and is,
by definition, equal to the treatment absorbed dose
level.
For external beam therapy, it has been recommended
that the target absorbed dose be the absorbed dose at
one or more specification points which are representa-
tive of the dose distribution throughout the target vol-
ume. These specification points could be established
with respect to the target volume or to the beam axes,
or both.
The situation is more difficult in intracavitary ther-
apy due to the steep dose gradient in the vicinity of the
sources, i.e., throughout the tumor or the target volume.
Under these conditions, the specification of the target
absorbed dose in terms of the absorbed dose at specific
point(s), in the vicinity of the sources, becomes less
meaningful and a different approach is required. In-
stead of a target-dose specification, a volume specifi-
cation is recommended.
Specification of an intracavitary application in
terms of the "reference volume" enclosed by the ref-
erence isodose surface is proposed in this Report.
However, as the different isodose surfaces are close to
each other, the indication of the reference volume must
be supplemented, for safety reasons, by the indication
of the total reference air kerma which, for radium
treatments, is proportional to the number of "mg·h". In
addition, a record of absorbed dose at reference points
related to organs at risk or to bony structures is rec-
ommended. The time-dose pattern shall also be clearly
indicated (see Section 4).
The present recommendations do not imply a modi-
fication of the method used for the calculation of the
treatment duration, but they imply the calculation of
specific quantities to be determined for reporting.
The recommendations presented in this Report must
be considered a minimum requirement for reporting.
On the other hand, the reported parameters will be
meaningful only to the extent that the technique of the
particular intracavitary application has been com-
pletely described.
This report deals mainly with the treatment of cervix
carcinoma for which the anatomical region of interest
is similar for every patient and the possible variation in
9
the position of the radioactive sources is limited. How-
ever, for other gynecological intracavitary situations the
same philosophy can be adopted, but some of the nu-
merical values and definitions may need to be modified
according to the type of application.
3.2 Description of the Technique
It is recommended that the technique be described
on the basis of the guidance given below.
Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016
3.2.1 The Sources
(i) radionuclide;
(ii) reference air kerma rates;
(iii) shape, filtration, etc.
3.2.2 Simulation of Linear Sources
a) When a linear source is simulated by a set of point
sources, the activity of these point sources and their
separation(s) must be indicated.
b) When moving sources are used to simulate a set of
different sources in fixed position, in order to pro-
duce an appropriate dose distribution, the following
indications are required:
(i) type of movement (continuous or stepwise, step
distance);
(ii) unidirectional or oscillating movement;
(iii) range of movement or oscillation;
(iv) speed in different sections of the applicator, or
dwell times of the source at different posi-
tions.
3.2.3 The Applicator
Reference to the applicator is sufficient when a
complete description has already been published, pro-
vided that there is no significant difference between the
applicator used and the one described in the literature.
To avoid confusion, it is recommended that the appli-
cator be described, including the name of the manu-
facturer. The description should include information
on the following points:
(i) rigid (or not), consequently with fixed known ge-
ometry (or not) of the complete applicator;
(ii) rigid uterine source with fixed curvature (or
not);
(iii) connection between vaginal and uterine applica-
tors, i,e., fixed, loose (semi-fixed), free;
(iv) type of vaginal sources, number and orientation of
line sources, special sources (box, ring, etc.);
(v) high atomic number shielding materials in vaginal
applicator (or not).
10 ... 3. Recommendations for Reporting Absorbed Doses and Volumes In Intracavitary Therapy

3.3 Recommendations for Reporting Plane a

Three approaches are proposed to specify intracavi-
tary application for cervix carcinoma; they complement
each other and it is recommended that they be com-
bined.

3.3.1 Total Reference Air Kerma

When radium was used exclusively, the product of the
"quantity of radioactive material" and the duration of
the treatment was given as minimal information. This
is the "concept of the mg·h". It becomes increasingly
difficult to use the product mg·h for specifying an in-
tracavitary application with other radionuclides, even
if milligrams of radium are replaced by the term "mil-
ligram-radium equivalent" which can be misleading (see

Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016

Appendix). As noted in Section 2.3, the use of total
reference air kerma is proposed in this Report. This
quantity is unambiguous and easy to calculate. It is Plane b
proportional to the integral dose to the patient and can
also serve as a useful index for radiation protection of
personnel.
In addition, the inverse square law applied to the total
reference air kerma allows evaluation, to a reasonable
-
approximation, of the absorbed dose delivered during
treatment at distances from the sources down to 20-10
cm. When the distance of a point P from the center C
of the volume occupied by the sources is larger than 2.5
times the largest dimension of that volume, the dose rate
obtained at P from the actual distribution of sources .... a
differs by less than 4% from that obtained by assuming
Fig. 3.1. Geometry for measurement of the size of the pear -shaped
that all of the sources are located at C (Dutreix et al., 60 Gy isodose surface (broken line) in a typical treatment of cervix
1982). carcinoma using one rod-shaped uterine applicator and 2 vaginal
However, the simple calculation of the total reference applicators. Plane a is the "oblique" frontal plane that contains the
air kerma does not allow one Wderive, even roughly, the intrauterine device. The oblique frontal plane is obtained by rotation
of the frontal plane around a transverse axis, Plane b is the "oblique"
absorbed dose in the immediate vicinity of the sources sagittal plane that contains the intrauterine device. The oblique
(Le., in the tumor or target volume) and, in particular, sagittal plane is obtained by rotation of the sagittal plane around AP
it should be stressed that an accurate and simple rela- axis. The height (db) and the width (d w) of the reference volume are
tion cannot be derived between total reference air kerma measured in plane a as the maximal sizes parallel and perpendicular
and absorbed doses at specific points such as A and B to the uterine applicator, respectively. The thickness (d t ) of the ref-
erence volume is measured in plane b as the maximal size perpen-
(see Figure 1.3.).
dicular to the uterine applicator.

3.3.2 Description of the Reference Volume

The description of the reference volume, i.e., the tis-
sue volume encompassed by a reference isodose surface,
is proposed for specification in reporting. The reasons
for this approach are described in Sections 2.2.1.,2.2.2.
and 3.1.
a. Dose Level
An absorbed dose level of 60 Gy is widely accepted
as the appropriate reference level for classical low
dose-rate therapy. When two or more intracavitary
applications are performed, the absorbed dose to con-
sider is that r~sulting from all applications. The time-
dose pattern should be clearly stated (see Section
4.2).
When intracavitary therapy is combined with ex-
ternal beam therapy, the isodose level to be considered
is the difference between 60 Gy and the dose delivered
at the same location by external beam therapy. For
example, if a dose of 20 Gy were delivered to the whole
pelvis by external beam therapy, the isodose level to be
considered would be 60 - 20 Gy = 40 Gy. Nevertheless,
it is recognized that the combined dose does not nec-

essarily produce the same effect as a similar dose from
intracavitary therapy alone.
For intracavitary therapy at medium or high dose
rates, the therapist has to indicate the dose level which
he believes to be equivalent to 60 Gy delivered at the
classical low dose rate and should clearly state this.
b. Reference Volume: Description of the Pear-Shaped
Volume
When uterine source(s) are combined with vaginal
sources, or when the uterine source is more heavily
loaded at the lower end, the tissue volume to be de-
scribed presents a pear shape with its longest axis
coincident with the intrauterine source. This reference
volume is defined by means of three dimensions (see
Figure 3.1):
(i) the height (d h ) is the maximum dimension along
the intrauterine source and is measured in the
oblique frontal plane containing the intrauterine
source;
(ii) the width (d w ) is the maximum dimension per-
pendicular to the intrauterine source and is mea-
sured in the same oblique frontal plane;
(iii) the thickness (d t ) is the -maximum dimension
perpendicular to the intrauterine source and is
measured in the oblique sagittal plane containing
the intrauterine source.
The definitions of dh, d w and d t are proposed in order
to minimize the number of calculations. These dimen-
sions are usually expressed in cm. The volume estimated
from the intersections of the surface of a pear-shaped
volume on two conventional planes does not necessarily
represent the size of the true reference volume. How-
ever, for most applications they do not differ from the
maximum dimensions of the reference volume by more
than 1 or 2 mm.
3.3.3 Absorbed Dose at Reference Points
Several reference points are in current use. Some are
relatively close to the sources and related either to the
sources or to organs at risk; others are relatively far from
the sources and are related to bony structures. The
following definitions apply to the case where the doses
are calculated from two perpendicular radiographs, AP
and lateral. When other methods are used, such as ste-
reographic x-ray films, oblique perpendicular radio-
graphs or transverse sections (CT scans), the calcula-
tions need to be modified.
a. Reference Points Close to the Sources and Related
to the Sources
As such points are located in a region where the dose
gradient is high, any inaccuracy in the determination
of distance results in large uncertainties in the absorbed
doses evaluated at these points. Such calculated ab-
sorbed doses do not, therefore, seem an appropriate
3.3 Recommendations for Reporting • • • 11
means of characterizing an intracavitary application
and/or of specifying the target absorbed dose, particu-
larly if rigid source combinations are not used. Such
points are not recommended.
b. Reference Points Relatively Close to the Sources but
Related to Organs at Risk
The determination and specification of the absorbed
dose to organs at risk (bladder, rectum, etc.) are ob-
viously useful with respect to normal tissue tolerance
limits. However, such information will be meaningful
only to the extent that it is obtained and expressed in
precise and well-codified ways.
(i) Calculated Values: Reference points for the ex-
pression of the absorbed dose to the bladder and the
absorbed dose to the rectum (see Figure 3.2.) have
been proposed by Chassagne and Horiot (1977).
Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016
The bladder reference point is obtained as fol-
lows. A Foley catheter is used. The balloon must be
filled with 7 cm3 of radio-opaque fluid. The catheter
is pulled downwards to bring the balloon against the
urethra. On the lateral radiograph, the reference
point is obtained on an anterio-posterior line drawn
through the center of the balloon. The reference
point is taken on this line at the posterior surface
of the balloon. On the frontal radiograph, the ref-
erence point is taken at the center of the balloon.
The point of reference for the rectal dose is ob-
tained as follows. On the lateral radiograph, an
anteroposterior line is drawn from the lower end
of the intrauterine source (or from the middle of the
intravaginal sources). The point is located on this
line 5 mm behind the posterior vaginal wall. The
posterior vaginal wall is visualized, depending upon
the technique, by means of an intravaginal mould
or by opacification of the vaginal cavity with a
balloon
7cm 3 point
nlctal
Fig. 3.2. Determination of the reference points for bladder and
rectum (see text).
12 ... 3. Recommendations for Reporting Absorbed Doses and Volumes In Intracavitary Therapy
(I)
Line taken
by probe ---.-
Doso-rato
motor
Mothod A
Doso-rat.
mlZhzr
Mdhod B
Fig. 3.3. Measurement of the rectal dose rate. Following the inser-
tion of the source applicators, either pre-loaded (low-activity treat-
ment) or manually loaded with low-activity sources identical in design
to those used during high-activity after-loaded treatment, the rectal
dose is measured_
Method A: The measuring probe is moved relative to a rigid
guide tube inserted into the rectum and held in position. The
point of maximum rectal dose rate is noted and the distance
"d" in cm from the anal verge deduced.
Method B: The measuring probe is moved so that the tip of
the probe is moved along the mid-line of the recto-vaginal sep-
tum until the point of maximum dose rate is reached_ Distance
is taken as a direct reading on the central tube at the anal
verge. The dose-rate and distance are recorded.
The major disadvantage of method" A" is that the probe tip cannot
follow closely the surface of the anterior rectal wall. However, allow-
ance for the distance of the probe sensor from the vagino-rectal sep-
tum needs to be taken into account.
radio-opaque gauze used for the packing. On the AP
radiograph, this reference point is at the lower end
of the intrauterine source or at the middle of the
intravaginal source(s).
(ii) Monitoring of the Absorbed Dose Rate to the
Rectum.- An alternative to calculating the rectal
dose is to measure the dose, or dose rate, at different
points along the anterior rectal wall to ensure that
no area of the rectal mucosa receives a dose above
the tolerance level. This type of measurement re-
quires special care in positioning the measuring
probe. An example is given in Figure 3.3_ (O'Connell
et al., 1967; Joslin et al., 1972).
c. Reference Points Related to Bony Structures
(i) The lymphatic trapezoid is obtained as follows (see
Figure 3.4): A line is drawn from the junction of
81-82 to the top of the symphysis_ Then a line is
drawn from the middle of that line to the middle of
the anterior aspect of U. A trapezoid is constructed
in a plane passing through the transverse line in the
pelvic brim plane and the midpoint of the anterior
aspect of the body of L4. A point 6 cm lateral to the
midline at the inferior end of this figure is used to
give an estimate of the dose rate to mid-external
iliac lymph nodes (labeled R. EXT and L. EXT for
Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016
right and left external, respectively). At the top of
the trapezoid, points 2 cm lateral to the midline at
the level of L4 are used to estimate the dose to the
low para-aortic area (labeled R. PARA and L.
PARA). The midpoint of a line connecting these
two points is used to estimate the dose to the low
common (labeled R. COM and L. COM) iliac lymph
nodes (from Fletcher, 1980).
(ii) The pelvic-wall reference point (Chassagne et al.,
1977) can be visualized on an AP and a lateral ra-
diograph and related to fixed bony structures. This
point is intended to be representative of the ab-
sorbed dose at the distal part of the parametrium
and at the obturator lymph nodes (see Figure 3.5.).
On an AP radiograph, the pelvic-wall reference
point is intersected by the following two lines: a
horizontal line tangential to the highest point of the
acetabulum, a vertical line tangential to the inner
aspect of the acetabulum. On a lateral radiograph,
the highest points of the right and left acetabulum,
in the cranio-caudal direction, are joined and the
lateral projection of the pelvic-wall reference point
is located at the mid-distance of these points.
Evaluation of the absorbed dose at reference points,
related to well-defined bony structures and lymph node
areas, is particularly useful when intracavitary therapy
is combined with external beam therapy. It is also useful
in helping to avoid an overdose when intracavitary
therapy is to be followed by surgery.
3.3.4. Calculation of Dose Distribution
The present recommendation, in particular the de-
scription of the reference volume encompassed by the
60-Gy isodose surface, necessitates the computation of
complete dose distributions in several planes.
The respective planes for which the dose distribunon
is to be computed will depend on the technique IUhl (I.e
particular clinical situation. However, as a millimum
 3.3 Recommendations for Reporting • . • 13

Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016

Fig. 3.4. Determination of the lymphatic trapezoid (see text). On the left is an anteroposterior view and on the right a lateral view.

A P X - RAY FILM LATERAL X -RAY FILM

Fig. 3.5. Determination of the right (RPW) and left (LPW) pelvic wall reference points (see text).
14 . . . 3. Recommendations for Reporting Absorbed Doses and Volumes In Intracavitary Therapy
requirement, it is recommended that the dose distri-
butions be computed in two planes: the oblique frontal
plane and the oblique sagittal plane both containing the
intrauterine source.
When practicable, it is recommended that dose dis-
tributions be calculated in additional sets of planes and
that these dosimetric data be correlated with that ob-
tained from radiographs or CT sections, in order to
determine the absorbed dose at any relevant anatomical
point.
While this additional information will be of value in
assessing effects in any individual patient, it will also
provide:
(i) the possibility of comparing the methods of spec-
ification used in different centers and of evaluating
their respective merits;
(ii) the possibility of comparing the methods of spec-
ification used in historical series (mg·h, points "A"
and "B") with the methods recommended in the
present Report;
(iii) the possibility of deriving new clinical and radio-
biological data and correlations which could im-
prove treatment techniques and develop further
the method of specification.
3.4 Definition of the 60 Gy Reference Volume in
Special Situations
3.4.1 One Linear Source Only
In some situations only one linear source is
present:
-in the case of a narrow vagina with a uterine source
protruding into the vaginal cavity,
-in the case of vaginal irradiation with a central source
from a cylindrical applicator.
In estimating the volume (Section 3.3.2.b) in this
simple case, the width is equal to the thickness.
3.4.2 Vaginal Sources Only
When only vaginal sources are present, width is the
largest dimension from right to left in an oblique frontal
plane through the main axis of the vagina.
Thickness is the largest dimension in a direction
perpendicular to the above oblique plane. Height is
measured along the vaginal axis, and is commonly
shorter than the other two dimensions.
3.4.3 Rigid Applicator
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Provided that there is a fixed connection between
vaginal and uterine sources, pre-calculated isodose
surfaces can be obtained for given loadings of the ap-
plicator. Therefore, pre-calculated dimensions of height,
width and thickness can be given (IAEA, 1972).
3.4.4 Uterine Packing (In Endometrial Cancer)
In connection with uterine packing, the same defi-
nitions of height, width and thickness given in Section
3.3.2 can be used. However, two facts need to be
noted:
-width and thickness are usually located at the level
of the uterine fundus (the pear-shaped volume is re-
versed),
-height should be determined in the oblique frontal
plane, which gives the maximum dimension.
 4. Time-Dose Pattern
4.1 Radiobiological Considerations
Radiobiological effects often depend on dose rate but
to a greater or lesser extent according to the actual level
of the dose rate and the nature of the effect (Hall, 1978).
For example, it is generally observed for mammalian
cells irradiated in vitro that for dose rates larger than
about 1 Gy·min- 1 survival is independent of dose rate,
but becomes increasingly dependent on dose rate at
lower rates. For dose rates below about 1 Gy·h- 1 survival
again becomes independent of dose rate.
The relationship between dose rate and tissue re-
sponse in vivo is complex because many factors have to
be taken into account such as cell distribution, repair
of potentially lethal lesions, and, for tumors, reoxyge-
nation. As far as cell proliferation is concerned, its role
is probably a minor one in brachytherapy applica-
tions.
In each brachytherapy application, there is neces-
sarily both a marked dose gradient and a marked dose
rate gradient as a function of distance from the
sources.
The possible importance of changes in time factors
(dose rate) in determining the biological or clinical effect
should not be underestimated since there may be a shell
of tissues surrounding the sources where differences in
15
dose rate may be significant (Van Limbergen et al.,
1985). Its location and thickness will vary with the total
reference air kerma rate and the application time. In
addition, the time between fractions is important in the
case of fractionated high dose-rate intracavitary
therapy.
It can be concluded that any significant change in the
source strength and the time-dose pattern should be
made with the greatest care. Furthermore, early tissue
reactions alone should not be used to select the pre-
scribed dose since late reactions, which are most rele-
vant, depend to a greater extent on dose rate.
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4.2 Recommendations for Reporting Time-Dose
Pattern
Sufficient data on the effect of dose-rate on various
tissues are not available at the present time. Therefore,
no correction factors for dose rate can be recommended,
but the duration of the application should be stated.
When more than one application is performed, the
duration of each should be reported, as well as the time
interval(s) between them.
Similarly, when external beam therapy and intra-
cavitary therapy are combined, the time-dose schedule
of the whole treatment should be reported.
 5. Conclusions and Final Recommendations
In intracavitary therapy, due to the high dose-rate
gradient, the specification of the target absorbed dose
as that dose observed at one (or several) reference
point(s) within the target volume or close to the sources,
does not appear to be meaningful. Under these condi-
tions, the same approach to reporting as in external
beam therapy cannot be recommended.
The following are proposed in this Report (see Table
0.1).
First, as already pointed out in ICRU Report 29
(ICRU, 1978), any method of specification will be
meaningful only to the extent that the treatment
different tissues or organs are directly proportional to
the total reference air kerma.
Third, it is recommended that the reference volume
be described in terms of the height, width and thick-
ness of the volume enclosed in the 60 Gy isodose surface
for cervix-carcinoma treatment by low dose rates. For
higher dose rates a dose level lower than 60 Gy has to be
selected.
Fourth, the absorbed dose at reference points in or-
gans at risk (rectum, bladder) should be determined
(computed or measured) and expressed in well-codified
ways to provide additional safety limits.
In addition, the absorbed dose(s) at reference point(s)

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technique has been completely described. related to bony structures (lymphatic trapezoid and
Second, the total reference air kerma should be pelvic-wall reference points) should also be reported.
stated. For a given method of application (source ge- Finally, the time-dose pattern should be completely
ometry and relative loads), the doses delivered at the specified.

TABLE 5.1-List of data needed for reporting intracavitary therapy in gynecology

Data Needed Paragraph Page

DESCRIPTION OF THE TECHNIQUE USED 3.2 9

TOTAL REFERENCE AIR KERMA (cGy at 1 metre) 3.3.1 10
DESCRIPTION OF THE REFERENCE VOLUME 3.3.2 10
-Dose level if not 60 Gy 3.3.2.a 10
-Dimensions of the reference volume (height, width, thickness) 3.3.2.b 11
ABSORBED DOSE AT REFERENCE POINTS 3.3.3 11
Bladder reference point 3.3.3b 11
Rectal reference point 3.3.3b 11
Lymphatic trapezoid 3.3.3c 12
Pelvic wall reference point 3.3.3c 12
TIME DOSE PATTERN 4 15

16
 APPENDIX
Specification of Radioactive Sources Used in Intracavitary Therapy
Only some aspects of the problem of the specification
of sources will be reported here since this topic will be
dealt with at length in a forthcoming ICRU Report and
has been treated recently (Dutreix et at., 1982).
(1) When radium tubes were the only radioactive
sources used in intracavitary therapy, their strength was
specified in terms of the mass of radium in mg con-
tained in the tube.
(2) When artificial radionuclides became available,
the sources were first specified in terms of their activity
in mCi.
(3) Due to the influence of self-absorption and fil-
tration within the source and its sheath, the "contained
activity" was of little practical interest and the concept
of "apparent activity" was introduced. The apparent
activity of a source was defined as the activity of a point
source of the same radionuclide which would deliver the
same exposure rate in air at the same distance from the
center ofthe actual source (the distance should be large
enough so that the actual source can be considered as
a "point source").
Instead of the term apparent activity, the expression
"equivalent activity" has also been used (IAEA, 1967
and ICRU, 1970), but it could lead to some confusion
with the expression "milligram-radium equivalent".
This is because sources of different radionuclides with
the same apparent activity will not give equivalent dose
distributions.
(4) In order to compare radium substitutes directly
with radium itself, sources were specified in "milli-
gram-radium equivalent". The radium equivalent mass
(mg-Ra equivalent) of a source is the mass of radium
filtered by 0.5 mm of platinum which leads to the same
exposure rate as that from the radioactive source of
interest at the same distance. Thus, the dose rate at a
given distance from a typical 10 mg radium tube filtered
by 1 or 2 mm of platinum is less than the dose rate de-
livered at the same distance by a 10 mg Ra equivalent
source which was standardized to 0.5 mm platinum.
(5) Later, the strength of a source was specified in
17
terms of its output, i.e., exposure rate at a reference
distance. The reference exposure rate in milliroentgens
per hour at 1 meter was used (mR·h- l ·m 2) (Wambersie
et at., 1973; NCRP, 1974; Dutreix, 1974; Dutreix and
Wambersie, 1975).
(6) Recently, the Comire Fran~ais pour la Mesure des
Rayonnements Ionisants (CFMRI, 1983) has recom-
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mended that radioactive sources be specified in terms
of "reference air kerma rate" ("debit de kerma normal
dans l'air"). The reference air kerma rate of a source is
the kerma rate to air, in air, at a reference distance of
one metre, corrected for air attenuation and scattering.
This quantity is expressed in ~Gy·h-l at 1 m. For ex-
ample, a "point" source containing 1 mg of radium, 0.5
mm Pt filtration, produces an exposure rate of 8.25 ±
0.10 R·h- l at 1 cm or 8.25 X 10- 4 R·h- l ·m 2. Taking into
account the conversion factor from exposure to air
kerma (0.873 cGy·R-l) and the correction for the dif-
ference in filtration (0.93), a source containing 10 mg of
radium, 1 mm Pt filtration, produces an air kerma rate
of 67 ~Gy·h-l at 1 m.
(7) The total reference air kerma is the sum of the
products of the reference air kerma rate and the dura-
tion of the application for each source.
By way of example, we consider an application per-
formed with 25 mg of radium as an intrauterine source
and 40 mg of radium as the vaginal sources. If the ra-
dium tubes are filtered by 1 mm Pt, 65 mg of radium
yield a reference air kerma rate of 435 ~Gy·h-l·m2.
Therefore, for example (for radioprotection purposes),
at one metre from the patient the dose equivalent rate
will not exceed about 0.4 mSv·h- l .
Assuming that the sources are left in situ for 6 days
(144 hours), the total reference air kerma is equal to 435
X 144 X 10-6 Gy or 6.27 cGy at 1 m. The dose delivered
to the sigmoid for example (assumed to be 10 cm from
the center of the sources) is approximately 6.27 X 102
cGy or 6.27 Gy, neglecting tissue attenuation and the
tissue-kerma to air-kerma ratio.
 References
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BUSCH, M. (1973). "Three-dimensional optimization
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BUSCH, M., MAKOSKI, B., SCHULTZ, U., and SAUER-
WEIN, K (1977). "Das Essener Nachlade-Verfahren
fur die intracavitare Strahlentherapie," Strahlen-
therapie 153,581.
CARDIS, R. and KJELLMAN, J. (1967). "Un nouvel ap-
pareil pour la radiotherapie endocavitaire; Ie cervi-
tron 2," Industries Atomiques, 11, 1.
CHASSAGNE, D., DELOUCHE, G., ROCOPLAN, J. A.,
PIERQUIN, B., and GEST, J. (1969). "Description et
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CHASSAGNE, D., GERBAULET, A., DUTREIX, A., and
COSSET, J. M. (1977). "Utilisation pratique de la
dosimetrie par ordinateur en curietherapie gyneco-
logique," J. Radiol. Electrol. 58, 387.
CHASSAGNE, D. and HORIOT, J. C. (1977). "Proposi-
tions pour une definition commune des points de
reference en curietherapie gynecologique," J. Radiol.
Electrol. 58, 371.
CFMRI (1983). Comite Fran~ais pour la Mesure des
Rayonnements Ionisants, Recommandations pour
la determination des doses absorbees en curieth-
erapie, Rapport CFMRI no. 1 (Bureau National de
Metrologie, Paris).
DUTREIX, A. (1974). "Une nouvelle methode de speci-
fication des sources radioactives en curietherapie,"
J. Radiol. Electrol. 55,781.
DUTREIX, A. and WAMBERSIE, A. (1968). "Etude de
la repartition des doses autour de sources ponctuelles
alignees. Application en curietherapie gynecolo-
gique," Acta Radiol. Ther. 7, 389.
DUTREIX, A. and WAMBERSIE, A. (1975). "Specifica-
tion of gamma-ray brachytherapy sources," Br. J.
Radiol. 48, 1034.
DUTREIX, A., MARINELLO, G., and WAMBI!,;H,l:;IE, A.
(1982). Dosimetrie en Curietherapie (Masson,
Paris).
FLETCHER, G. H. (1980). "Squamous cell carcinoma of
the uterine cervix" p. 720 in Textbook of Radio-
therapy (Lea & Febiger, Philadelphia).
HALL, E. J. (1978), Radiobiology for the Radiologist
(Harper & Row, Hagerstown, Maryland).
HENSCHKE, U. K, HILARIS, B. S., and MAHAN, G. D.
(1966). "Intracavitary radiation therapy of cancer of
18
the uterine cervix by remote afterloading with cycling
sources," Am. J. Roentgenol. 96,45.
HIMMELMANN, A., KARLSTEDT, K, and RAGNHULT,
I. (1980). "Early experience with high dose-rate
(Ralstron) treatment in Goteborg" p. 106 in High
Dose-Rate Afterloading in the Treatment of Cancer
of the Uterus, Bates T. D. and Berry R. J., Eds., Br.
J. Radiol. Special report 17.
IAEA (1967). International Atomic Energy Agency,
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Vienna).
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Atlas of Radiation Dose Distributions. Vol. IV,
Brachytherapy Isodose Charts. Sealed radium
sources. M. Stovall, L. H. LanzI, W. S. Moos, Eds.
(International Atomic Energy Agency, Vienna).
ICRU (1970). International Commission on Radiation
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Activity Gamma-Ray Sources, ICRU Report 18
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and Electrons, ICRU Report 29 (International
Commission on Radiation Units and Measurements,
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JOSLIN, C. A., LIVERSAGE, W. E., and RAMSEY, N. W.
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PATERSON, R. and PARKER, H. M. (1934). "A dosage
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curietherapie et Plesiocurietherapie (Masson,
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TwIss, D. H. and BRADSHAw, A. L. (1970). "Automatic
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VAN DER LAARSE, R. (1981). "Computerized radiation
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VAN LIMBERGEN, E., CHASSAGNE, D., GERBAULET,
A., and HAlE, C. (1985). "Different dose rates in
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Relerences ••. 19
carcinoma," J. Eur. Radioth. (to be published in ·
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VON ESSEN, C. F. (1980). "Clinical application of the
Brachytron: the San Diego technique for treatment
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Afterloading in the Treatment of Cancer of the
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WALSTAM, R. (1954). "The dosage distribution in the
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 IeRU Reports
IeRU Reports are distributed by the IeRU Publications' office. Information
on prices and how to order may be obtained from:
IeRU Publications
7910 Woodmont Avenue, Suite 1016
Bethesda, Maryland 20814
U.S.A.
The currently available IeRU Reports are listed below.
ICRU
Report No. Title
lOb Physical Aspects of Irradiation (1964)

Downloaded from http://jicru.oxfordjournals.org/ at University of Glasgow on July 9, 2016

10c Radioactivity (1963)
lOf Methods of Evaluating Radiological Equipment and Ma-
terials (1963)
12 Certification of Standardized Radioactive Sources (1968)
13 Neutron Fluence, Neutron Spectra and Kerma (1969)
14 Radiation Dosimetry: X Rays and Gamma Rays with Max-
imum Photon Energies Between 0.6 and 50 MeV (1969)
15 Cameras for Image Intensifier Fluorography (1969)
16 Linear Energy Transfer (1970)
17 Radiation Dosimetry: X Rays Generated at Potentials of 5
to 150 k V (1970)
18 Specification of High Activity Gamma-Ray Sources
(1970)
20 Radiation Protection Instrumentation and Its Application
(1971)
22 Measurement of Low-Level Radioactivity (1972)
23 Measurement of Absorbed Dose in a Phantom Irradiated by
a Single Beam of X or Gamma Rays (1973)
24 Determination of Absorbed Dose in a Patient Irradiated by
Beams of X or Gamma Rays in Radiotherapy Procedures
(1976)
25 Conceptual Basis for the Determination of Dose Equivalent
(1976)
26 Neutron Dosimetry for Biology and Medicine (1977)
27 An International Neutron Dosimetry Intercomparison
(1978)
28 Basic Aspects of High Energy Particle Interactions and
Radiation Dosimetry (1978)
29 Dose Specification for Reporting External Beam Therapy
with Photons and Electrons (1978)
30 Quantitative Concepts and Dosimetry in Radiobiology
(1979)
31 Average Energy Required to Produce an Ion Pair (1979)
32 Methods of Assessment of Absorbed Dose in Clinical Use of
Radionuclides (1979)
33 Radiation Quantities and Units (1980)
34 The Dosimetry of Pulsed Radiation (1982)
35 Radiation Dosimetry: Electron Beams with Energies Be-
tween 1 and 50 MeV (1984)
36 Microdosimetry (1983)
37 Stopping Powers for Electrons and Positrons (1984)
20
 ICRU Reports ..• 21
38 Dose and Volume Specification for Reporting Intracavitary
Therapy in Gynecology (1985)

Binders for ICRU Reports are available. Each binder will accommodate
from six to eight reports. The binders carry the identification, "ICRU Re-
ports," and come with label holders which permit the user to attach labels
showing the Reports contained in each binder.
The following bound sets of ICRU Reports are also available:
Volume I. ICRU Reports lOb, lOc, lOf
Volume II. ICRU Reports 12, 13, 14, 15, 16, 17, 18,20
Volume III. ICRU Reports 22, 23, 24, 25, 26
Volume IV. ICRU Reports 27, 28, 29, 30, 31, 32
Volume V. ICRU Reports 33, 34, 35, 36
(Titles of the individual Reports contained in each volume are given in the
list of Reports set out above.)

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The following ICRU Reports were superseded by subsequent Reports and
are now out of print:
ICRU
Report No Title and Reference*
1 Discussion on International Units and Standards for X-ray
Work, Brit. J. Radio!. XXIII, 64 (1927).
2 International X-Ray Unit of Intensity, Brit. J. Radio!' (new
series) I, 363 (1928).
3 Report of Committee on Standardization of X-ray Mea-
surements, Radiology 22,289 (1934).
4 Recommendations of the International Committee for Ra-
diological Units, Radiology 23, 580 (1934).
5 Recommendations of the International Committee for Ra-
diological Units, Radiology 29, 634 (1937).
6 Recommendations of the International Commission on
Radiological Protection and of the International Com-
mission on Radiological Units, National Bureau of Stan-
dards Handbook 47 (U.S. Government Printing Office,
Washington, D.C., 1951).
7 Recommendations of the International Commission for
Radiological Units, Radiology 62,106 (1954).
8 Report of the International Commission on Radiological
Units and Measurements (ICRU) 1956, National Bureau
of Standards handbook 62 (U.S. Government Printing
Office, Washington, D.C., 1957).
9 Report of the International Commission on Radiological
Units and Measurements (ICRU) 1959, National Bureau
of Standards Handbook 78 (U.S. Government Printing
Office, Washington, D.C., 1961).
lOa Radiation Quantities and Units, National Bureau of Stan-
dards Handbook 84 (U.S. Government Printing Office,
Washington, D.C., 1962).
lOd Clinical Dosimetry, National Bureau of Standards Handbook
87 (U.S. Government Printing Office, Washington, D.C.,
1963).
lOe Radiobiological Dosimetry, National Bureau of Standards
Handbook 88 (U.S. Government Printing Office, Wash-
ington, D.C., 1963).
22 ... ICRU Reports

11 Radiation Quantities and Units (International Commission

on Radiation Units and Measurements, Washington, D.C.,
1968).
19 Radiation Quantities and Units (International Commission
on Radiation Units and Measurements, Washington, D.C.,
1971).
19S Dose Equivalent [Supplement to ICRU Report 19] (Inter-
national Commission on Radiation Units and Measure-
ments, Washington, D.C., 1973)
21 Radiation Dosimetry: Electrons with Initial Energies Be-
tween 1 and 50 Me V (International Commission on Ra-
diation Units and Measurements, Washington, D.C.,
1972).
• References given are in English. Some of the Reports were also published in other languages.

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 Index
Absorbed dose at reference points, 11 Rectal reference point, 11
Absorbed-dose pattern, 5 Reference air kerma rate, 8, 17
Activity, 17 Reference dose level, 7,10
Manual afterloading, 5 Reference exposure rate, 17
Remotely controlled afterloading, 5 Reference isodose surface, 7
Apparent activity, 17 Reference points, 1-2,9, 11-12, 13
Applicator, 9 Bladder reference point, 11
Lymphatic trapezoid, 12
Bladder reference point, 11 Rectal reference point, 11
Points A and B, 1-2
Calculation of dose distribution, 12 Reference volume, 7, 9,10,11, 14
Conclusions and final recommendations, 16

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Simulation of linear sources, 4, 9
Definition of terms and concepts currently used in intracavitary Special situations, 14
therapy, 4 Source specification, 17
Definition of the 60 Gy reference volume in special situations, 14 Activity, 17
Description of the technique, 9 Apparent activity, 17
Description of the volume, 10 Mass of radium, 17
Dose rate, 4-5 Milligram-radium equivalent, 17
High dose rate, 5 Reference air kerma rate, 17
Low dose rate, 4 Reference exposure rate, 17
Medium dose rate, 5 Specification, 8, 9
Duration of the treatment, 9, 15 Intracavitary application, 9
Radioactive sources, 8, 9, 17
Irradiated volume, 1,7 Target dose specification, 9
Volume specification, 9
Linear sources, 4, 9 Stockholm system, 1-2
Simulation, 4, 9 Systems, 1-2
Lymphatic trapezoid, 12 Manchester system, 1-2
Paris system, 1-2
Manchester system, 1-2 Stockholm system, 1-2
Milligram hours (mg·h), 1, 10
Target volume, 1,5
Organs at risk, 8, 9 Time-dose pattern, 9, 15
Total reference air kerma, 8, 9, 10, 17
Paris system, 1-2 Treatment techniques, 4, 5, 9
Pear shaped volume, 11 Afterloading techniques, 5
Pelvic-wall reference point, 12-13 Treatment volume, 1, 7

Radioactive sources, 4, 8, 9 Volume, 1,5,7,9, 10-11

Radiobiological considerations, 15 Irradiated volume, 7
Radium substitutes, 4 Pear shaped volume, 11
Recommendations for reporting absorbed doses and volumes in Reference volume, 7, 9, 10, 11
intracavitary therapy, 9 Target volume, 1, 5
Recommendations for reporting time-dose pattern, 15 Treatment volume, 1,7
Rectal dose rate (measurement), 12 Volume specification, 9

23