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Design and implementation of a film dosimetry audit tool for comparison of planned and

delivered dose distributions in high dose rate (HDR) brachytherapy

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2013 Phys. Med. Biol. 58 6623

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IOP PUBLISHING PHYSICS IN MEDICINE AND BIOLOGY
Phys. Med. Biol. 58 (2013) 6623–6640 doi:10.1088/0031-9155/58/19/6623

Design and implementation of a film dosimetry audit

tool for comparison of planned and delivered dose
distributions in high dose rate (HDR) brachytherapy

Antony L Palmer 1,2,6 , Chris Lee 3 , Ailsa J Ratcliffe 4 , David Bradley 1

and Andrew Nisbet 1,5
1 Department of Physics, Faculty of Engineering and Physical Science, University of Surrey,
GU2 7JP, UK
2 Medical Physics Department, F-Level, Queen Alexandra Hospital, Portsmouth Hospitals NHS

Trust, Portsmouth, PO6 3LY, UK

3 Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, CH63 4JY, UK
4 Department of Clinical Physics and Bioengineering, University Hospitals Coventry and

Warwickshire NHS Trust, CV2 2DX, UK

5 Medical Physics Department, Royal Surrey County Hospital NHS Foundation Trust,

Guildford, GU2 7XX, UK

E-mail: antony.palmer@porthosp.nhs.uk

Received 29 April 2013, in final form 17 July 2013

Published 9 September 2013
Online at stacks.iop.org/PMB/58/6623

Abstract
A novel phantom is presented for ‘full system’ dosimetric audit comparing
planned and delivered dose distributions in HDR gynaecological brachytherapy,
using clinical treatment applicators. The brachytherapy applicator dosimetry
test object consists of a near full-scatter water tank with applicator and
film supports constructed of Solid Water, accommodating any typical cervix
applicator. Film dosimeters are precisely held in four orthogonal planes
bisecting the intrauterine tube, sampling dose distributions in the high risk
clinical target volume, points A and B, bladder, rectum and sigmoid. The
applicator position is fixed prior to CT scanning and through treatment planning
and irradiation. The CT data is acquired with the applicator in a near clinical
orientation to include applicator reconstruction in the system test. Gamma
analysis is used to compare treatment planning system exported RTDose grid
with measured multi-channel film dose maps. Results from two pilot audits are
presented, using Ir-192 and Co-60 HDR sources, with a mean gamma passing
rate of 98.6% using criteria of 3% local normalization and 3 mm distance to
agreement (DTA). The mean DTA between prescribed dose and measured film
dose at point A was 1.2 mm. The phantom was funded by IPEM and will be
used for a UK national brachytherapy dosimetry audit.
(Some figures may appear in colour only in the online journal)

6 Author to whom any correspondence should be addressed.

0031-9155/13/196623+18$33.00 © 2013 Institute of Physics and Engineering in Medicine Printed in the UK & the USA 6623
6624 A L Palmer et al

1. Introduction

Dosimetric audits are quality assurance processes that enable confirmation of the dosimetric,
and ideally also geometric, accuracy of dose delivery, normally conducted by external visiting
physicists or postal audits. Accurate dosimetry is required in radiotherapy to increase the
likelihood of desired treatment outcomes (increased tumour control and reduced treatment
toxicity), minimize the risk of error in routine practice, and guarantee the validity of clinical
trial results (Dixon and O’Sullivan 2003). To date, radiotherapy audit has primarily focused on
external beam treatment (Nisbet and Thwaites 1997, Nisbet et al 1998, Palmer et al 2011) and
in comparison there has been a relative lack of activity for brachytherapy. Whilst the physical
process by which high dose rate (HDR) brachytherapy treatment units delivery dose is relatively
simple in comparison to external beam units, the complexity of brachytherapy techniques have
seen recent significant developments and the quality assurance task for HDR brachytherapy is
not without difficulty, involving high dose gradients, large dose ranges and small dimensions.
Dosimetric audit is equally valid and necessary for brachytherapy as for external beam
radiotherapy. There are examples of brachytherapy treatment errors: 32 incidents discussed in
IAEA Safety Reports Series No.17 (IAEA 2000), more than 500 incidents (everything from
planning to transport problems) reported in ICRP Publication No. 97 (ICRP 2005), a source
calibration error reported by Dempsey (2011) and various unexpected equipment performance
(Stern and Liu 2010, Palmer 2013a). There are also uncertainties in the HDR source itself;
DeWerd et al (2011) stated ‘the vast majority of sources demonstrate variations of 2%–20%
in the intensity of emissions about the long axis,’ which are assumed to be uniform given
the cylindrical symmetry. The available quality control (QC) measurement recommendations
for HDR brachytherapy are generally device-centred and limited to performing checks on
individual performance aspects including positional accuracy, timer accuracy, source strength,
transit dose, source model data, and there is some variation between centres’ QC schedules
(Palmer et al 2012c). The overall dose accuracy is a combination of all equipment performance
parameters, and is influenced by the presence of the actual clinical treatment applicator. There
is a need for QC tests which verify the overall dose distribution, and associated dosimetric
audits to confirm and demonstrate required accuracy.
There have been several dosimetric audits of HDR brachytherapy undertaken during
the last two decades. All published audits have verified source strength or dose at one or
several points, using irradiation from simple straight catheters rather than clinical treatment
applicators. One of the first audits was conducted by Elfrink et al (2001) in which three straight
catheters arranged symmetrically around a central in-air ionization chamber was used to verify
dose delivery accuracy for 21 HDR units in The Netherlands and Belgium. A cubic phantom
was also used for applicator reconstruction tests. A similar in-air measurement with ionization
chamber was conducted by Heeney et al (2005) for five HDR units in Ireland, Scotland and
Northern England. Roue et al (2006) reported on the EQUAL-ESTRO audit of applicator
geometric reconstruction for HDR brachytherapy. Three straight catheters around a central
measuring point was used by Roue et al (2007) for a European mailed dosimetry audit using
thermoluminescent dosimeters (TLD), in a PMMA phantom. TLD was also used by Ochoa
et al (2007) for a mailed dosimetry audit of source strength at seven Brazilian centres. Tedgren
and Grindborg (2008) audited source strength using a well-chamber at 14 centres in Sweden.
More recently, Casey et al (2012) has developed a remote audit tool in USA using optically
stimulated luminescence dosimetry to measure dose at two points from a single straight
catheter, and Haworth et al (2009, 2013) has completed a pilot audit in seven Australian
centres using TLD to measure dose at a single point from six dwell positions uniformly
distributed in three straight catheters. There is also a UK audit of well chamber consistency
HDR brachytherapy film dosimetry audit tool 6625

being conducted during 2012–13 by Lee et al 2013, Clatterbridge Cancer Centre (as yet
unpublished) and there have been audits using TLD around clinical applicators conducted by
the Midlands Audit Group in UK (unpublished).
While audits as described above are important to establish source strength and check
basic parameters, additional complexity of the dosimetric audit approach is required to fully
establish the accuracy of treatment planning system (TPS) calculations and the performance
of treatment equipment with clinical treatment applicators in as near to the actual treatment
situations as possible. The purpose of this work is to approach HDR brachytherapy audit
from a novel perspective: to measure dose distributions around clinical treatment applicators
and compare to TPS isodose calculations, rather than traditional audits in brachytherapy of
point doses from straight catheters. The measurement is therefore more closely aligned with
external beam patient-specific QC for IMRT/VMAT delivery verification than conventional
brachytherapy QC tests. Point dosimeters or well-chambers are therefore replaced by 2D film-
dosimetry in this work, and comparison between measured film-dose and TPS calculation is
analysed by gamma evaluation.
Radiochromic film is an established dosimeter for radiotherapy dose measurements
(Butson et al 2003, Devic 2011), primarily used to verify external beam dosimetry it has
also been widely used in brachytherapy applications (Devic et al 2009, Aldelaijan et al 2011,
Hira et al 2011, Ghorbani et al 2012, Uniyal et al 2012, Palmer et al 2013b). Film technology,
scanning and analysis techniques have developed significantly in the last decade, and the
latest Gafchromic EBT3 with multi-channel analysis is now advocated for accurate dose
measurement (Micke et al 2011, van Hoof et al 2012). Gafchromic film provides high spatial
resolution, can be used in water, and is near water equivalent (Zeff, EBT3 = 6.73 compared to
Zeff, water = 7.3 (Crijns et al 2013)). In general, Gafchromic film exhibits relatively low energy
dependence (Arjomandy et al 2010, Sarfehnia et al 2010), with EBT3 exhibiting the lowest
variation with energy for HDR brachytherapy applications (Brown et al 2012).
The uncertainty in any measurement system should be significantly less than the variations
to be measured in the test signal. There are uncertainties in film dosimetry, including positional,
scanning, darkening kinetics and energy response. These can be mitigated by modern film
dosimetry methods, and any residual uncertainty is expected to be acceptable for the intended
purpose of this work. This assumption is tested in this study. The test object is designed not to
precisely establish TG-43 type dose-rate functions (Rivard et al 2004) but to confirm the dose
distributions around clinical treatment applicators is consistent with TPS calculated intended
distributions, within acceptable tolerance. An increased level of uncertainty is acceptable for
this purpose.
The standard analysis method used in external beam radiotherapy to compare intended
and delivered dose distributions is the gamma evaluation index (Low et al 1998, Low and
Dempsey 2003, Low 2010), being the method of choice in most commercial verification
software. However gamma has been little used in brachytherapy due simply to an absence
of investigations comparing delivered and planned dose distributions in this modality.
A significant difference between external beam and brachytherapy dose distributions is the
much larger range of dose levels present in the latter, and it follows that a locally-normalized
(rather than globally normalized) gamma calculation is required for brachytherapy (Palmer
et al 2013b). If a single high-dose global normalization point is used for gamma calculations in
brachytherapy, any deviations in the much lower dose regions would be rendered insignificant.
The gamma calculation passing rate could be artificially increased simply by including a
larger region of lower doses in the analysis. Local normalization allows the percentage dose
difference to be applied at each dose level, avoiding biasing the gamma calculation passing
rate to only the high dose region.
6626 A L Palmer et al

The Institute of Physics and Engineering in Medicine (IPEM) have funded the
development of the brachytherapy audit tool which is intended to be used initially for a
national audit in the United Kingdom (UK) together with a complementary test object using
alanine to measure dose to a point, which has been developed in conjunction with the NCRI
Radiotherapy Trials Quality Assurance Team (RTTQA) and the National Physical Laboratory
(NPL), Teddington, UK. The alanine test object will provide confirmation of source strength,
the design objective of the film phantom is therefore primarily to verify dose distribution
around clinical treatment applicators. In a survey of UK radiotherapy centres conducted in
2012–2013, all of the 35 responding brachytherapy centres expressed a desire to take part in
the national audit, confirming the perceived need. Following completion of the national audit,
the brachytherapy audit tool will be available in IPEM’s phantom library for any UK centre to
use in commissioning or QC audits of brachytherapy equipment.

2. Methods and materials

2.1. Use and validation of EBT3 Gafchromic film for HDR brachytherapy dosimetry
All film measurements were performed with Gafchromic EBT3 film (Ashland ISP Advanced
Materials, NJ, USA), adopting AAPM TG-55 recommendations for film handling (Niroomand-
Rad et al 1998). Film scanning was performed in red–green–blue (RGB) format using a
48-bit (16-bit per channel) scanner (Epson Perfection V750 Pro) at 72 dpi, in transmission
mode, with no colour or sharpness corrections, consistent orientation on the scanner and 48 h
from exposure to scanning. A nominal 6 MV linear accelerator, traceably calibrated to a
primary standard at the National Physical Laboratory (Teddington, UK) and measured using
an ionization chamber calibrated for absorbed dose to water, was used for film calibrations.
Film strips of 10 × 5 cm were positioned on the central axis in a 10 × 10 cm field at
5 cm depth in Solid Water (RMI457, Gammex, Wisconsin, USA) and each exposed to a
different dose level: 0, 100, 200, 400, 800, 1000, 1500, 2000 cGy. The average film pixel
values in a 4 × 4 cm region centred on the axis of the beam were used to derive the average
film response at each dose level, establishing a calibration of the film as a function of the
three colour channels. Experimental films were converted to dose maps using an RGB multi-
channel algorithm via FilmQAPro R
software (Ashland ISP Advanced Materials, NJ, USA,
version 3.0.4835.12312) (Micke et al 2011). The multi-channel analysis method separates the
scanned signal into a dose-dependent part and a dose-independent part that enables corrections
for a variety of disturbances including non-uniformities in the film active layer and artefacts
from the film scanner. All HDR measurement films were exposed contemporaneously with a
dose reference film at the linac, to a known dose level approximately 75% of the maximum
expected HDR measurement dose, from the same film batch. This allowed linear scaling of
film calibration functions to correct for any residual time-since-exposure darkening kinetics
of the film calibration and any inconsistencies in the film scanner compared to the calibration
scans (Lewis et al 2012).
The response of EBT3 film to irradiation from a single HDR source was compared to
consensus data sets based on Monte Carlo models (Perez-Calatayud et al 2012) as a simple
method to experimentally validate the use of the film dosimetry system for HDR brachytherapy
(dose ranges, dose rates, and energy spectrums). This was done for both Ir-192 and Co-60 HDR
sources using a custom made Perspex film holder in a near full-scatter water tank (based on the
design described by Palmer et al 2013b) using plastic source transfer tubes. The repeatability
of results was assessed for both the Ir-192 and Co-60 sources using a second measurement
for each. Any dose-rate effect on film response was evaluated by exposing films to the same
HDR brachytherapy film dosimetry audit tool 6627

dose level but at different distances from the source and hence different dose rates, using
appropriately calculated irradiation times. Expected dose was calculated from Monte Carlo
derived TG-43 data and knowledge of the source strength and exposure time. This analysis
was performed for an Ir-192 source, similar work having previously been undertaken for a
Co-60 HDR source (Palmer et al 2013b).

2.2. Test object design

The test object was designed to measure the dose distributions around any ring/ovoids and
intrauterine (IU) clinical treatment applicator for HDR brachytherapy for cervix cancer. The
use of additional interstitial needles was not accommodated in the design.
The reference medium recommended by the AAPM Task Group 43 for obtaining the
dose rate distribution around a brachytherapy source is liquid water (Rivard et al 2004).
Non-water and finite size phantoms may introduce measurement differences from the TG-43
source model data used in the majority of current TPS (Perez-Calatayud et al 2012). The
brachytherapy applicator dosimetry (‘BRAD’) test object has been designed to maximize
the volume of liquid water around the applicator and film with all supporting and alignment
material constructed of Solid Water (Gammex, WI, USA model RMI-457) which introduces
acceptable corrections from liquid water (Perez-Calatayud et al 2012). Aldelaijan et al (2011)
has quantified the ratio of dose delivered to radiochromic film in liquid water compared to
the dose delivered in Solid Water using Monte Carlo simulations to be 0.9941 ± 0.0007.
Thin sheets of Solid Water, 5 mm thickness, are used to accurately position the film. Perez-
Calatayud et al (2004) showed that for Ir-192, the measurement of radial dose function in a
phantom of radius 200 mm would differ from that obtained in an unbound water phantom
by 1% up to 75 mm from the source and 2.5% at 100 mm from the source. There is a
practical limitation on the size of a water tank used for dosimetric audit measurements for
ease of transportation. There is also an argument that the scattering volume should equate
to approximate patient dimensions to compare delivered and planned dosimetry, rather than
unbound scattering conditions. Considering these competing factors, the audit phantom was
designed as follows: measurements up to 100 mm from the source using films located centrally
within a cubic water phantom of each dimension 400 mm (64 l).
The BRAD test object enabled four films to be placed in orthogonal planes crossing the
IU tube of the clinical treatment applicator, as shown in figure 1. The applicator ring or ovoids
were placed in contact with the upper surface of the test object with the IU tube inserted into
the central column. Collars and spacers matched to the external diameter and length of the
IU tube were inserted into the central column to ensure accurate positioning of the applicator
along the central axis of the test object. An applicator support arm and clamp were used to
rigidly hold the applicator in a consistent position for CT scanning and radiation delivery. One
EBT3 Gafchromic film of dimensions 100 × 120 mm was positioned on each of four vanes
in the test object, with the film moved up against end stops towards the central axis and upper
surface of the test object, giving a reproducible film-edge-to-IU-axis distance of 10.0 mm and
a film-edge-to-surface-of-applicator-ring distance of 5.0 mm. The evaluated region was film
edge to 60 mm away from the IU and film edge to 80 mm along the IU, (the unused portion
of film was for ID marking and handling). The film positions were intended to sample the
dose distribution through the majority of the high risk clinical target volume (HR-CTV) and
into typical locations of organs at risk: left lateral and right lateral films containing CTV and
conventionally defined points A and B (Viswanathan and Thomadsen 2012); the anterior film
including CTV and the closest section of typical bladder; and the posterior film including CTV
and closest sections of typical rectum and sigmoid, for cervical cancer brachytherapy.
6628 A L Palmer et al

Figure 1. Wireframe CAD drawing of ‘BRAD’ (brachytherapy applicator dosimetry) test object,
showing one film (yellow shading) in position. Side view shown on left, and top view shown on
right. One insert and spacer show above. Applicator support arm shown without clamp detail.
Position of applicator ring and IU tube indicated in green with position of point A indicated by red
dot. All dimensions in mm.

2.3. Procedure for HDR brachytherapy dosimetry audit

To provide an ‘end to end’ system test of brachytherapy dosimetry, it was essential that all
normal operating procedures were utilised for the phantom as for patients, including CT scan
protocol, data transfer, planning process, export system, and treatment.

2.3.1. CT scan. For each audit, a clinical cervix treatment applicator was selected and
appropriate collars and spacers inserted into the central cavity of the BRAD phantom to match
the outer dimension of the IU tube and the distance from ring/ovoid surface to IU tip. The
applicator was inserted into the phantom as illustrated in figures 1, 2 and the clamp adjusted and
secured to ensure no movement. The phantom was placed on its side such that the applicator
was in an approximate clinical position and then CT scanned using the audit centre’s normal
gynaecology brachytherapy protocol.

2.3.2. Treatment plan. Using normal clinical protocols, the applicators were reconstructed
on the CT images and a typical cervix treatment plan prepared, either prescribing to point A
or noting its dose. Confirmation that the locally used definition of point A was as defined by
the 2012 ABS recommendations (Viswanathan and Thomadsen 2012) was established, or a
correction applied. If required, simulated CTV and OARs were drawn or copied from existing
HDR brachytherapy film dosimetry audit tool 6629

(a) (b)

Figure 2. ‘BRAD’ test object with EBT3 film for measurement of HDR dose distribution
(a) shown from side with Nucletron microSelectron treatment unit with ring and IU applicator
used with Ir-192 source, and (b) from above with Eckert & Ziegler BEBIG split-ring and IUT
applicator used with Co-60 source.

CT scans, to test inverse planning algorithms. Alternatively, standard loading patterns were
used. The DICOM RTDose grid for the plan was exported for later comparison to film dose
measurements.

2.3.3. Treatment delivery. An EBT3 film was positioned on each vane of the phantom,
ensuring contact with the central and upper end-stops, and secured in place using the film
clamps. The phantom was then placed vertically in the custom water tank and irradiated
according to the imported treatment plan.

2.4. Film analysis

Experimental films were converted to dose maps using FilmQAPro software as described
above. Point A is conventionally defined as 20 mm from the surface of the ring/ovoid
and 20 mm lateral from the IU tube axis (Viswanathan and Thomadsen 2012). Films were
positioned in the phantom with edges at 5 mm from the ring/ovoids and 10 mm from the
IU axis, hence the geometric position of point A was established on both lateral films at
coordinates 15 mm from the film edge in the direction of the IU axis (along) and 10 mm
from the film edge orthogonal to the IU axis (away). The film dose at point A was compared
to the prescribed/noted dose at point A from the TPS and a distance to agreement (DTA) on
the film calculated. Due to the very high dose gradients, the DTA was used as the quality
evaluation parameter rather than the absolute dose difference at the position of point A. While
local centres need to establish what they consider a ‘clinically relevant’ DTA, for the purposes
of audit design, 3.0 mm DTA was considered an ‘acceptable’ tolerance value for the audit
measurement.
Dose distributions were compared between film and TPS using visual isodose overlay
and gamma evaluation index, as implemented in the FilmQAPro R
software (Ashland
ISP Advanced Materials, NJ, USA, version 3.0.4835.12312). The gamma calculation in
FilmQAPro software uses the average film dose calculated to the same resolution as the
TPS dose grid, hence eliminating film noise effects artificially improving the gamma score.
6630 A L Palmer et al

Figure 3. Film dose, two separate measurements, as a function of radial distance from an isolated
Ir-192 HDR source (Nucletron/Elekta microSelectron source model V2 105.002) compared to
Monte Carlo source model data (Daskalov et al 1998) normalized at 20 mm radial distance. Error
bars shown at 7.6% expanded uncertainty (k = 2).

A notation ‘x% (local)/y mm’ has been adopted to represent gamma criteria with dose
difference of x% normalized locally with y mm distance to agreement. Gamma criteria of
3% (local)/3 mm and 3% (local)/2 mm were used in the analysis, having been proposed as
suitable for HDR brachytherapy by Palmer et al (2013b). A lower threshold limit of 0 cGy was
applied to the film dose map (dose-independent signal having been removed by the analysis
algorithm). Gamma is used here as a benchmark and the results for each audit are compared
to the normal range of gamma in this measurement and analysis situation, derived from pilot
and initial audits, to establish what is ‘acceptable.’ Results outside this tolerance were to be
inspected in more detail.

2.5. Pilot dosimetry audit and repeatability

Pilot dosimetry audits were conducted at (a) The Clatterbridge Cancer Centre NHS Foundation
Trust, UK, using a Nucletron microSelectron HDR treatment unit with Ir-192 HDR source
(mHDR-v2 105.002) and Oncentra treatment planning system (v4.0), and (b) Queen Alexandra
Hospital, Portsmouth Hospitals NHS Trust, UK, using an Eckert & Zeigler Bebig HDR
MultiSource with a Co-60 HDR source (Co0.A86) and HDRPlus treatment planning system
(v3.0). Figure 2 shows photos of the BRAD phantom in use at the pilot audit centres. To
evaluate repeatability of results, a second measurement was performed at each pilot centre and
results compared.

3. Results

3.1. Validation of EBT3 film dosimetry

Figure 3 shows EBT3 film results from two separate measurements of the radial dose (direction
perpendicular to the source axis) away from the centre of a microSelectron Ir-192 HDR source,
HDR brachytherapy film dosimetry audit tool 6631

Figure 4. Film dose, two separate measurements, as a function of radial distance from an isolated
Co-60 HDR source (Eckert & Ziegler Bebig source model Co0.A86) compared to Monte Carlo
source model data (Granero et al 2007) normalized at 20 mm radial distance. Error bars shown at
7.6% expanded uncertainty (k = 2).

compared to Monte Carlo derived TG-43 source model data (Daskalov et al 1998, Daskalov
2000). Agreement between film dose and Monte Carlo data was within 4% in the range 7.5 to
20 mm from the source, equivalent to 800 cGy to 100 cGy dose, increasing to 7% variation at
distances beyond 30 mm, less than 50 cGy. Figure 4 shows results of the same measurement
for an Eckert & Ziegler BEBIG MultiSource Co-60 HDR source, compared to Monte Carlo
derived TG-43 source model data (Granero et al 2007). Agreement between film dose and
Monte Carlo data was within 4% in the range 7.5 to 40 mm, equivalent to 1000 to 35 cGy,
increasing to 5% beyond 50 mm, less than 20 cGy. Repeatability of result was within 3% for
both sources.
Figure 5 shows film dose results of radial distance away from an Ir-192 source from two
separate exposures, the ‘low dose’ film receiving an irradiation time approximately ten times
less than the ‘high dose’ film. The expected dose is also shown, calculated from Monte Carlo
source model data (Daskalov et al 1998) and knowledge of source strength and irradiation
time. At approximately 100 cGy, the low irradiation time film dose is within 1% of expected,
and the high irradiation time film is within 3% of expected. Considering all the data, there is
no significant dose-level or dose-rate effect on the agreement between film dose and Monte
Carlo data calculated expected dose. This finding is consistent with previous work conducted
for a Co-60 source (Palmer et al 2013b).

3.2. Pilot dosimetry audits

Figure 6 provides an isodose overlay from two films irradiated within the BRAD phantom
from a typical cervix treatment with clinical ring and IU tube applicator comprising multiple
dwells of an Ir-192 source, on two separate occasions. The applicator was situated above and
to the right of the film. Comparison of the two dose distributions by gamma analysis gave a
passing rate of 99.9% at 1% (local)/1 mm criteria. Two film measurements were made in each
6632 A L Palmer et al

Figure 5. Comparison of film response at different dose rates (distances from the source), for an
Ir-192 HDR source. Dose range 50–800 cGy delivered in range 5–35 cm in low dose film and
20–100 cm in high dose film. Calculated expected dose is from Monte Carlo data and knowledge
of source strength and irradiation time. Error bars shown at 7.6% expanded uncertainty (k = 2).

Figure 6. Repeatability of film dose measurement in ‘BRAD’ test object. Isodose lines from EBT3
films in the left lateral position in the phantom (CTV, points A and B), from two independent
measurements (first measurement thick lines, second measurement thin lines), for a typical cervix
treatment with multiple dwells from an Ir-192 source.
HDR brachytherapy film dosimetry audit tool 6633

Figure 7. Enlargement of isodose map from EBT3 film exposed in ‘BRAD’ test object with typical
cervix plan prescribed to 8.5 Gy at point A, Co-60 HDR source. The geometric location of point
A is shown as a red dot on the graph.

of the four film positions in the phantom, exposed to both Ir-192 and Co-60 sources. In all
cases, passing rates exceeded 95% at 1% (local)/1.5 mm.
Figure 7 provides isodoses from a section of a film irradiated within the BRAD phantom
from a typical cervix treatment with clinical ring and IU tube applicator and a Co-60 source,
at the corner of the film closest to the applicator. The applicator was situated below and to the
left of the film, in this image. The geometric position of point A is indicated with a red dot
on the graph, at a position 10 mm ‘away’ from the film edge (ordinate) and 15 mm ‘along’ from
the film edge (abscissa). The film has not been scaled or re-normalized, and in this case shows
the prescription isodose of 850 cGy passing through the intended prescription position at point
A. The DTA from the position of point A on the film to the position of the intended prescription
isodose was calculated for each test film: left lateral and right lateral films, measured twice
for both Ir-192 and Co-60. For the Ir-192 pilot irradiation, a prescription of 700 cGy to point
A was planned, and for Co-60 pilot, a prescription of 850 cGy to point A was planned. The
DTA for all films was between 0.2 and 2.1 mm, with mean DTA of 1.2 mm; 1.8 mm for Ir-192,
0.6 mm for Co-60 irradiations. The uncertainty in evaluation of DTA is 1.1 mm (k = 2).
Figures 8 and 9 show example isodose charts from the pilot dosimetry audits using the
BRAD phantom, for Ir-192 and Co-60 HDR sources, respectively. The charts show the EBT3
film dose (thin lines) compared to the TPS calculated isodose (thick lines), over a range 50 to
1300 cGy. The film dose has not been scaled or re-normalized. Figure 8 shows anterior and
right lateral films, and figure 9 shows left lateral and posterior films, with respect to the clinical
orientation of the treatment applicator in the phantom. Displacement between film and TPS
isodoses is generally within 1 mm at the higher dose levels and within 2–3 mm at the lower
dose levels.
Table 1 provides gamma analysis results of the agreement between the measured EBT3
film dose and the corresponding plane from the TPS exported RTDose grid, from the pilot
 6634
Table 1. Gamma analysis between film and TPS dose distributions for Ir-192 HDR unit at Clatterbridge Cancer Centre and Co-60 HDR unit at Queen Alexandra Hospital, Portsmouth.
Evaluated film region is 60 mm away × 80 mm along from ring/IU. Film and TPS dose distributions manually aligned prior to evaluation.

Trial 1, gamma passing rate Trial 2, gamma passing rate

Source isotope Film location in ‘BRAD’ phantom with
and HDR unit respect to clinical applicator position 3% (local)/2 mm 3% (local)/3 mm 3% (local)/2 mm 3% (local)/3 mm

Ir-192 Anterior: CTV and bladder 99.5% 99.9% 99.2% 99.7%

Nucletron Posterior: CTV and rectum/sigmoid 98.4% 99.5% 93.9% 99.9%
microSelectron Left lateral: CTV, points A and B 99.1% 99.9% 98.9% 99.6%
v2 Right lateral: CTV, points A and B 97.4% 99.9% 99.8% 100.0%
Co-60 Anterior: CTV and bladder 92.5% 97.3% 87.5% 95.1%
Eckert & Zeigler Posterior: CTV and rectum/sigmoid 93.5% 98.3% 97.8% 99.6%
Bebig HDR Left lateral: CTV, points A and B 92.0% 97.2% 90.2% 97.6%
MultiSource Right lateral: CTV, points A and B 93.2% 97.1% 92.7% 97.7%

A L Palmer et al
HDR brachytherapy film dosimetry audit tool 6635

(a) (b)

Figure 8. Isodose comparison between EBT3 film dose (thin lines) and TPS calculation (thick
lines) in film positions (a) anterior (CTV to bladder), and (b) right lateral (CTV, points A and B),
for a typical cervix treatment with an Ir-192 source.

(a) (b)

Figure 9. Isodose comparison between EBT3 film dose (thin lines) and TPS calculation (thick lines)
in film positions (a) left lateral (CTV, points A and B), and (b) posterior (CTV to rectum/sigmoid),
for a typical cervix treatment with a Co-60 source.

audits. The results from two measurements for both Ir-192 and Co-60 are provided. At gamma
criteria 3% (local)/3 mm, all passing rates exceeded 95%, with a mean passing rate of 98.6%.
At gamma criteria of 3% (local)/2 mm, all passing rates exceeded 87.5%, with a mean passing
rate of 95.3%. Repeatability of results between trial 1 and 2 showed average change in passing
rate of 1.5%, with a range 0.1% to 4.5%. It is not possible from these results to determine if
this represents uncertainty in the film–phantom system or variations in the HDR unit delivery,
6636 A L Palmer et al

but is within the uncertainty budget calculation, section 3.6. No specific film locations showed
better or worse results than the others.

3.3. Uncertainty analysis

A robust understanding of the overall uncertainty budget is required to establish criteria
for the determination of an ‘out of tolerance’ result in audit measurements. This includes
film dosimetry within the BRAD phantom as well as uncertainty of the TPS TG-43 model
calculation, applicator reconstruction on CT, and HDR treatment delivery under normal
operating conditions. An estimate of the combined uncertainty has been calculated using a
simple quadrature sum of individual components of the dosimetry system as detailed in table 2.
The expanded uncertainty, k = 2, is estimated as 6.4% (combined standard uncertainty 3.2%).
This represents the uncertainty in the determination of point dose differences between TPS
calculated and film measured doses. Due to varying dose gradients across the film, positional
uncertainties have a variable effect on dose uncertainty, the prior values being evaluated in the
vicinity of point A.
The uncertainty in dose DTA at point A is estimated as 1.1 mm (k = 2), from a 6.4% dose
uncertainty in a typical 6% mm−1 dose gradient.
For dose measurements as a function of radial distance from an isolated source,
figures 3–5, the film positional uncertainty is increased to 1.0 mm, the effect on dose is
dose-gradient dependent, but taken as 6%, and the applicator position uncertainty replaced
with source position within catheter uncertainty, 0.3 mm, taken as 1.8% effect on dose. The
expanded uncertainty, k = 2, is estimated as 7.6%.

4. Discussion

The use of Gafchromic EBT3 film in the dose range, dose rates, and energies required for HDR
brachytherapy dose distribution measurement have been investigated. For both Ir-192 and Co-
60 HDR sources, the film dose as a function of radial distance from the source agrees well
with Monte Carlo reference data in higher dose regions, but deteriorates with under-response
and increased noise if the film dose is less than around 100 cGy. This is in line with previous
studies for EBT (Chelminski et al 2010) and EBT3 (Palmer et al 2013b). For measurements
of dose distributions in clinically relevant situations, such as CTV volume or nearest high
dose region in organs at risk, doses will exceed this level. While not explicitly investigated,
any energy dependence of the film due to departure from water equivalence, to both Co-60
and Ir-192 HDR source irradiation, has been deemed acceptable in the results obtained in
comparison to Monte Carlo data and treatment planning system calculations.
The results of the study have shown EBT3 film with multi-channel analysis is a dosimetry
system capable of dose distribution measurement for the purposes of QC, commissioning
checks, or dosimetric audits. The intention of this work was not to verify or determine
TG-43 type source model parameters, but to undertake QC measurements of dose distributions
around clinical treatment applicators as a ‘system test’ for brachytherapy dosimetry. There is an
important distinction between the inherent dosimetric accuracy achievable in the measurement
system, and the required accuracy of the measurement system to assess whether a clinically
acceptable level of agreement exists between the intended treatment plan and the measured
dose distribution.
The determination of a ‘clinically relevant’ departure between intended and actually
delivered radiation dose distribution is difficult to define and depends on local factors for each
radiotherapy centre. It is likely to be in the region of a dose difference greater than 5.0%, or a
HDR brachytherapy film dosimetry audit tool 6637

Table 2. Uncertainty budget for the experimental determination of the agreement between
TPS planned and BRAD phantom film measured dose distributions, at ‘expected’ uncertainty
under normal operating conditions and good-practice processes. Calculation is for absolute dose
difference at a point (using dose gradient at point A).
Uncertainty
Component Source of uncertainty Type (k = 1) Notes

Applicator Applicator position in CT data set B 2.25% a

reconstruction
TPS calculation Monte Carlo derived TG-43 model parameters B 0.5% b
HDR treatment Source strength A 0.4% c
equipment delivery Uncertainty in source dwell position under B 1% d
normal operation
Film dosimetry Linac calibration for reference exposures B 0.5% e
Film calibration fit function B 0.5% f
Film position B 0.9% g
Energy dependence B 1.5% h
Phantom scatter (deviation from unbounded) A 0.5% i
Film scanning process A 0.2% j
Combined standard uncertainty (k = 1) 3.2%
Expanded uncertainty (k = 2) 6.4%
Notes.
a Applicator reconstruction on phantom CT images may depend on CT slice width, and is expected to have less

uncertainty than reported estimates of uncertainty in clinical practice (Tanderup et al 2008, Hellebust et al 2010). A
0.75 mm uncertainty in applicator reconstruction has been used, the dose effect is dependent on proximity to the
source, but a typical value of 4.5% is determined (from typical 6% mm−1 dose gradient at point A) at coverage k = 2.
b Estimate based on general Monte Carlo uncertainty, for relative dose distribution only not absolute cGy h−1 U−1.
c Uncertainty in calibration of well chamber at NPL, IPEM/NPL HDR code of practice (Bidmead et al 2010).

Estimate of uncertainty in use of calibrated well chamber to determine source strength is not additionally included.
d Uncertainty in HDR treatment equipment performance under normal operating conditions may include 1.0 mm

systematic error in source position as largest typical factor. The dose effect is dependent on position, but a typical
value of 2% is used at coverage k = 2 (Palmer et al 2012b). Normal variations in dwell time or transit dose are not
expected to contribute significant uncertainty.
e Uncertainty taken from IPSM 1990 MV Code of Practice (Lillicrap et al 1990).
f Consistency of multichannel film calibration and estimated uncertainties from film analysis software.
g Film position uncertainty estimated at 0.3 mm, at coverage k = 2, in BRAD phantom. The dose effect is dependent

on proximity to the source, but a typical value of 1.8% is used (from typical 6% mm−1 dose gradient at point A) at
coverage k = 2.
h The energy dependence uncertainty of EBT3 film is taken as the correction from calibration in 6 MV to

measurement in HDR energies, estimated as 3% at coverage k = 2 from Brown et al (2012).

i Representative value for bounded scatter taken as 1% at 7.5 cm from source, from Perez-Calatayud et al (2004).

While a coverage factor is not quoted, we have assumed k = 2.

j From study of repeatability of film scanning, after lamp warm-up.

shift in isodose position of greater than 3.0 mm. The clinically acceptable passing rate for a
gamma analysis in HDR brachytherapy is particularly problematic to establish, with no prior
published work having considered this concept. Gamma is therefore used here as a benchmark
and the results for each audit are compared to the normal range of gamma established for
this particular measurement and analysis situation, derived from pilot and initial audits, to
establish what is ‘acceptable.’ Pilot audits have shown agreement evaluated with gamma index
of passing rates exceeding 95% for 3% (local)/3 mm criteria. It is suggested that a passing
rate of 90% is desirable and 80% should be investigated, at 3% (local)/3 mm, although host
physicists will need to interpret the results of the audit in terms of their own local practice.
Further investigation will include confirmation of basic system operation and data (dwell
6638 A L Palmer et al

position, dwell time, source strength, TG-43 source model data, applicator reconstruction)
and may include evaluating regions of gamma failure, further analysis of the gamma metric,
comparison to existing independent measurements or repeat measurement. Results should also
be considered in the context of the achievable accuracy in brachytherapy and other significant
clinical and physiological uncertainties in the treatment process (Palmer et al 2012a).
The dosimetry phantom is not specifically designed for absolute dose measurement for
the purposes of source strength assessment, however it is of course possible to assess delivered
dose with calibrated EBT 3 film. The expanded uncertainty in point dose comparison using the
experimental techniques described was estimated as 5% at k = 2. While the UK brachytherapy
dosimetry audit is designed to use the BRAD phantom for evaluation of dose distribution,
in combination with an alanine phantom for the evaluation of source strength, the agreement
between film measured dose and prescribed dose is encouraging based on the limited set of
pilot audit results. The mean DTA of the prescribed dose level from the geometric position of
point A using film dosimetry was 1.2 mm in the pilot audits. An acceptable limit of 3.0 mm
DTA is suggested for purposes of brachytherapy audit using the BRAD-film phantom.

5. Conclusions

Film dosimetry methods have been successfully used for the measurement of dose distributions
in HDR brachytherapy, validating the use of EBT3 Gafchromic film with multi-channel
analysis for dose measurements from both Ir-192 and Co-60 HDR sources at the required
accuracy and uncertainty for QC or audit purposes. The objective of the study was to develop
and implement a method for dosimetric quality assurance auditing, or commissioning, of
HDR brachytherapy systems, in terms of the variation between planned and delivered dose
distributions; this objective has been achieved. The ‘end to end’ dosimetry evaluation includes
CT scanning, applicator reconstruction, treatment planning and delivery of radiation, which
importantly and uniquely uses clinical treatment applicators. The design of the BRAD phantom
has been discussed and documented. The results from two pilot audits and repeatability study
have been presented showing mean DTA of prescribed isodose to point A of 1.2 mm, and
mean gamma passing rate between TPS and measured dose distribution of 98.6% at 3%
(local)/3 mm. All of the results were within defined acceptable tolerance values.

Acknowledgments

The authors gratefully acknowledge: Peter Pryce and colleagues in the engineering workshop
at the Clatterbridge Cancer Centre for construction of the audit tool; the Institute of Physics
and Engineering in Medicine (IPEM) for funding; Vertec UK and Ashland ISP USA for the
supply of Gafchromic EBT3 film. We appreciate support from the IPEM Working Party on
brachytherapy audit (2012–2013), National Physical Laboratory, UK, and NCRI Radiotherapy
Trials Quality Assurance Team (RTTQA), which included: Edwin Aird, Margaret Bidmead,
Peter Bownes, Patricia Diez, Laura Gandon, Clare Gouldstone, Chris Lee, Gerry Lowe,
Elizabeth Miles, Rebecca Nutbrown, Tony Palmer, Ailsa Ratcliffe, Thorsten Sander, and
Tania Simnor.

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