Recommendations of the American Association of Physicists in Medicine

regarding the Impact of Implementing the 2004 Task Group 43 Report

on Dose Specification for 103Pd and 125I Interstitial Brachytherapy
Jeffrey F. Williamsona兲
Chair, Photon-Emitting Brachytherapy Dosimetry Subcommittee of the Radiation Therapy Committee,
Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia 23298
Wayne Butler
Schiffler Cancer Center, Wheeling Hospital, Wheeling, West Virginia, 26003
Larry A. DeWerd
Accredited Dosimetry and Calibration Laboratory, University of Wisconsin, Madison, Wisconsin, 53706
M. Saiful Huq
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania,
15232
Geoffrey S. Ibbott
Radiological Physics Center, M.D. Anderson Cancer Center, Houston, Texas, 77030
Zuofeng Li
Department of Radiation Oncology, Washington University, St. Louis, Missouri, 63110
Michael G. Mitch
Ionizing Radiation Division, National Institute of Standards and Technology, Gaithersburg, Maryland,
20899
Ravinder Nath
Department of Therapeutic Radiology, Yale University, New Haven, Connecticut, 06510
Mark J. Rivard
Department of Radiation Oncology, Tufts-New England Medical Center, Boston, Massachusetts, 02111
Dorin Todor
Consultant, Photon-Emitting Brachytherapy Dosimetry Subcommittee, Department of Radiation Oncology,
Virginia Commonwealth University, Richmond, Virginia, 23298
共Received 23 November 2004; revised 14 February 2005; accepted for publication 14 February 2005;
published 27 April 2005兲
In March 2004, the recommendations of the American Association of Physicists in Medicine
共AAPM兲 on the interstitial brachytherapy dosimetry using 125I and 103Pd were reported in Medical
Physics 关TG-43 Update: Rivard et al., 31, 633–674 共2004兲兴. These recommendations include some
minor changes in the dose-calculation formalism and a major update of the dosimetry parameters
for eight widely used interstitial brachytherapy sources. A full implementation of these recommen-
dations could result in unintended changes in delivered dose without corresponding revisions in the
prescribed dose. Because most published clinical experience with permanent brachytherapy is based
upon two widely used source models, the 125I Model 6711 and 103Pd Model 200 sources, in this
report we present an analysis of the dosimetric impact of the 2004 TG-43 dosimetry parameters on
the history of dose delivery for these two source models. Our analysis indicates that the currently
recommended prescribed dose of 125 Gy for Model 200 103Pd implants planned using previously
recommended dosimetry parameters 关AAPM 103Pd dose prescription: Williamson et al., Med. Phys.
27, 634–642 共2000兲兴 results in a delivered dose of 120 Gy according to dose calculations based on
the 2004 TG-43 update. Further, delivered doses prior to October 1997 varied from 113 to 119 Gy
for a prescribed dose of 115 Gy compared to 124 Gy estimated by the AAPM 2000 report. For 125I
implants using Model 6711 seeds, there are no significant changes 共less than 2%兲. Practicing
physicians should take these results into account when selecting the clinically appropriate pre-
scribed dose for 103Pd interstitial implant patients following implementation of the 2004 TG-43
update dose-calculation recommendations. The AAPM recommends that the radiation oncology
community review this report and consider whether the currently recommended dose level 共125 Gy兲
needs to be revised. © 2005 American Association of Physicists in Medicine.
关DOI: 10.1118/1.1884925兴

103
Key words: Pd, 125I, permanent interstitial brachytherapy, air-kerma strength, dose prescriptions

1424 Med. Phys. 32 „5…, May 2005 0094-2405/2005/32„5…/1424/16/$22.50 © 2005 Am. Assoc. Phys. Med. 1424
1425 Williamson et al.: Dose specification for 103
Pd and
I. INTRODUCTION
In April 2000,1 the American Association of Physicists in
Medicine 共AAPM兲 published recommended administered-to-
prescribed dose ratios, 共DTx / DRx兲t, for 103Pd permanent seed
implants. These ratios, which are a function of time period t,
describe the systematic impact of changes in source-strength
standards and single-source dosimetry parameters on clinical
dose specification. The originally published 共DTx / DRx兲t ratios
related prescribed doses, DRx t , calculated in time periods t
ranging from 1988 to 1999 using contemporaneous
共ca. 1999兲 source strength standards and dosimetry param-
Tx
eters, to administered doses, D99 , based upon an updated
dose-rate constant and the National Institute of Standards
and Technology 共NIST兲 primary air-kerma strength standard,
SK,N99, using the wide-angle free-air chamber 共WAFAC兲2
which had been implemented on 1 January, 1999. The up-
dated dose-rate constant for the Model 200 103Pd seed
共TheraSeed®兲 was obtained by averaging a TLD
measurement3 with a value derived from Monte Carlo
simulation.4 The AAPM 2000 report concluded that for doses
of 115 Gy prescribed in the periods 1988–1997 and 1997–
1999, the corresponding administered doses were 124 and
135 Gy, respectively. Based on the AAPM 2000 recommen-
dations, the American Brachytherapy Society5 recommended
that the standard prescribed dose of 115 Gy for definitive
treatment of prostate cancer using 103Pd brachytherapy alone
be adjusted to 125 Gy.
This report presents updated guidance from the AAPM on
the issue of 103Pd and 125I brachytherapy dose reconstruction,
and was prepared by the AAPM Photon-Emitting Brachy-
therapy Dosimetry 共PEBD兲 Subcommittee 共Chair, J. Will-
iamson兲 and approved by the AAPM Radiation Therapy
Committee and Science Council. Because several unantici-
pated developments occurring after the publication of the
2000 recommendations1 impacted its recommended dose ra-
tios by more than 5%, PEBD believed that the issue of pre-
scribed dose selection for 103Pd brachytherapy needed to be
revisited. These developments include:
• Identifying and correcting a 5.3% error in NIST
SK,N99 calibration measurements performed in 1999
for the Model 200 source.
• Subsequent revisions of dosimetry parameters, most
notably the one-dimensional 共1D兲 anisotropy func-
tion.
• Recent revisions in the 1D dose-calculation formal-
ism recommended by AAPM,6 resulting in replace-
ment of the anisotropy constant by the 1D anisotropy
function.
• Publication4,7 of reference-quality Monte Carlo
single-source dosimetry parameters that distinguish
between the “heavy” seed 共low specific-activity
reactor-produced radioactive palladium兲 and “light”
seed 共higher specific-activity accelerator-produced
radioactive palladium兲 versions of the Model 200
source. These publications indicated a small change
共1.2%兲 in the dose-rate constant and a 2.3% change
in the anisotropy constant.
Medical Physics, Vol. 32, No. 5, May 2005
125
I interstitial brachytherapy 1425
• An improved formalism for estimating 共DTx / DRx兲t
ratios.
In contrast to 103Pd brachytherapy, no significant changes
were anticipated for 125I implant dosimetry. AAPM guidance
last addressed the issue of dose prescription for 125I implants
in 1998.8 The AAPM recommended that clinics reduce the
prescribed dose for 125I implant monotherapy from 160 to
144 Gy upon simultaneously adopting dosimetric parameters
recommended by the 1995 TG-43 report9 and implementing
the NIST 1999 SK primary standard. Since implementation of
this standard in 1999, no significant shifts in source strength
for this source model have occurred. In particular, the ven-
dor’s source strength calibration procedures for the Model
6711 source were not affected by the NIST measurement
anomalies of 1999. The revised TG-43 dose-calculation for-
malism and Model 6711 dosimetry parameters published in
20046 did not significantly alter the single-seed dose-rate dis-
tribution for this source. However, because of the 2004
changes in 125I recommended dose-calculation practice and
the modified methodology for estimating 共DTx / DRx兲t ratios
presented in this report, PEBD believed it was necessary to
reevaluate dose ratios for 125I as well as 103Pd brachytherapy.
II. METHODS AND MATERIALS
A. Brief history of 103
Pd brachytherapy dosimetry
The history of 103Pd brachytherapy dosimetry is inti-
mately related to that of the first 103Pd interstitial source
product, Theragenics Corporation’s Model 200 TheraSeed®,
introduced to the market in 1987. The early evaluated clini-
cal experience, published by Prestidge et al.10 in 1997, was
based upon patients treated with the Model 200 source dur-
ing the period 1988–1994. Later in 2000, Sharkey et al.11
reported the clinical experience with 1048 patients with 103Pd
implants treated from 1991 to 1999. Thus for clinicians prac-
ticing today who wish to reproduce the doses prescribed by
these investigators, knowing the equivalent dose to deliver,
based upon currently recommended dose-computation and
calibration practices, is essential, regardless of what com-
mercial 103Pd seed product they choose to use. Hence the
dosimetric history of 103Pd brachytherapy is equivalent to
that of the Model 200 commercial product.
In the following sections, important events in the history
of the Model 200 source dosimetry and development of air-
kerma strength 共SK兲 standard are reviewed.
1. Theragenics™ calibration standard „1988–1997…
Prior to the implementation of the 1999 NIST WAFAC
standard, a primary SK standard was not available for 103Pd
or any other low-energy interstitial seed with the exceptions
of the 3M 共now Amersham Health兲 125I seeds, Models 6701,
6702, and 6711.12 Thus, Theragenics™ developed a method
for measuring apparent activity using a NaI共Tl兲 scintillation
detector, which compared Model 200 103Pd seed photon
emission rate with the 22 keV emission line 共the average
energy of the 103Pd seed emission spectrum兲 from a 109Cd
 Pd Source. tTG43U1⬎ March 2004 denotes the date on which the revised TG-43 recommendations were implemented.
103

1426
Medical Physics, Vol. 32, No. 5, May 2005

TABLE I. Prescription and reference dose calculation parameters for the model 200

Era Dose-rate constant Radial dose function Anisotropy function Comments

Reference dosimetry data

Williamson et al.: Dose specification for

1988⬍ t 艋 1993 ⌳02D,N99S = 0.694 gL,02D共r兲 ␾an,04D共r兲 Heavy seed era
Monroe and Williamson 2002 ␾¯ an,04D = 0.884 No updated TG-43
Monroe–Williamson 2002 report recommendations

1993⬍ t 艋 present ⌳04D,N99S = 0.686
2004 TG-43 report
recommendation
Average of Nath and Monroe
gL,04D共r兲 ␾an,04D共r兲 Light seed era Equation 共6兲 used
Monroe and Williamson 2002 ␾
¯ an,04D = 0.862
as recommended by Monroe-Williamson data per 2004 TG-43
TG-43 2004 recommendation

Prescription dosimetry data

1988⬍ t 艋 3 / 00, 95D dosimetry TG-43 ⌳95D,T88S = 0.74 g P,95D共r兲 ␾

¯ an,95D = 0.90 Equation 共11兲 assumed
1995 report recommendations

3 / 00⬍ t 艋 3 / 01, 00D dosimetry ⌳00D,N99S = 0.665 g P,95D共r兲 ␾

¯ an,95D = 0.90 Equation 共11兲 assumed
AAPM 2000 Report ⌳00D,N99S based on CY 1999 SK,N99 calibrations.

103
recommendations Continued use of TG 43 1995

Pd and
relative dose functions
recommended

125
3 / 01艋 t 艋 present ⌳01D,N99S = 0.68 g P,95D共r兲 ␾
¯ an,95D = 0.90 Unchanged from

I interstitial brachytherapy
Theragenics implements corrected above except that
WAFAC standard measured ⌳00D,N99Sadjusted by 5%.

t ⬎ tTG43U1 , 04D dosimetry, TG-43 2004 ⌳04D,N99S = 0.686 g P,04D共r兲 ␾

¯ an,04D = 0.862 Equation 共11兲 assumed
Report data but using ␾¯ an,04D andgL,04D G P共r兲

t ⬎ tTG43U1 , 04D dosimetry, TG-43 2004 ⌳04D,N99S = 0.686 gL,04D共r兲 ␾an,04D共r兲 Equation 共6兲 assumed
Report data but ␾an,04D共r兲 and gL,04D GL共r兲

1426
1427 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1427

TABLE II. Dummy TG-43 dose calculation parameters for the Model 200
Pd-103 source.

0.912

0.880

0.979

0.957

0.975

1.000
D60
Heavy seed Light seed

Clinical implant averaging

⌳ 0.694 0.686
¯⬘
“Dummy” ␾ 0.875 0.855
an

Distance (cm) “Dummy” radial dose function, g⬘(r)

0.10 0.986 1.014
0.15 1.338 1.347
0.25 1.520 1.525
0.30 1.502 1.502

0.880

0.979

0.957

0.980

1.000
0.911
TABLE III. Prescription and reference dose calculation parameters. tTG43U1⬎ March 2004 denotes the date on which the revised TG-43 recommendations were implemented.

D90
0.40 1.403 1.412
0.50 1.288 1.284
0.60 1.229 1.228
0.75 1.143 1.143
0.80 1.107 1.114
1.00 1.000 1.000
1.50 0.762 0.761
2.00 0.572 0.571
2.50 0.426 0.426

G共r兲- weighted single-seed

3.00 0.318 0.316
3.50 0.235 0.235

approximation
4.00 0.174 0.173

0.907

0.876

0.974

0.953

0.996

1.000
5.00 0.095 9 0.094 4
6.00 0.052 9 0.051 8
7.00 0.033 0 0.028 4
7.50 0.023 1 0.022 3
10.00 0.007 35 0.006 70

calibration standard, which had a NIST-traceable activity

calibration with an assigned uncertainty of ⫾ 5%. More de-
RDF equivalence
approximation

tails are given in the 2000 report.1 The resultant apparent

0.921

0.887

0.987

0.966

1.000

1.000
activity, Aapp,T88, denotes the quantity measured by Theragen-
ics™ assay, where the “T” of the subscript “Tnn” denotes
Theragenics™ and “nn” denotes the year that the 109Cd stan-
dard, to which the measurement is traceable, e.g., 1992 for
the “T92” 109Cd standard, was implemented. Note that
Aapp,Tnn is fundamentally different from apparent activity as
defined by the AAPM,13 Aapp,N99, which is a quantity derived
from NIST’s 1999 standard, SK,N99. The vendor’s apparent
activity assay can be related to the vendor’s air-kerma t ⬎ tTG43U1 04D dosimetry parameters and recommended
strength by
3 / 00⬍ t 艋 3 / 01 AAPM 2000 dosimetry parameters

t ⬎ tTG43U1 04D dosimetry parameters 1995 TG-43

3 / 01⬍ t 艋 tTG43U1 ⌳ adjusted for 2000 WAFAC

SK,Tnn = Aapp,Tnn · 共⌫␦兲x · 共W/e兲

1988⬍ t 艋 1993 Heavy seed era

1993⬍ t 艋 3 / 00 Light seed era

1D formalism Equation 共11兲

1D formalism Equation 共6兲

= Aapp,Tnn · 1.293 ␮Gy · m2 · h−1 · mCi−1 ,

95D dosimetry parameters

95D dosimetry parameters

共1兲
Averaging approximation

where the exposure-rate constant for 103Pd, 共⌫␦兲x, and mean

correction
Era

energy expended per ion pair created, 共W / e兲, take the nu-
merical values recommended by the AAPM.13
Because of the 463.3 day half life of 109Cd,14 four succes-
sive calibration sources were used during the period 1988–
1997. Pairwise sequential intercomparisons between the old
and replacement standards permitted changes in SK,Tnn rela-
tive to SK,N99 to be reconstructed.1 Prior to implementing the
T97 calibration source in October 1997, these variations
were less than 2%.

Medical Physics, Vol. 32, No. 5, May 2005

1428 Williamson et al.: Dose specification for 103
Pd and
2. Early single-source dosimetry parameters
„1990–1995…
During the 1988–1990 time period, both Meigooni et al.15
and Chiu-Tsao et al.16 used TLD dosimetry to measure the
dose-rate constant and relative two dimensional 共2D兲 dose
distribution parameters. These investigators measured the ab-
solute dose rate at 1 cm on the transverse axis, and normal-
ized this measurement to the SK,T88 inferred from the ven-
dor’s Aapp,T88 value to obtain an estimate of the dose-rate
constant. The dose-rate constant recommended by the 1995
AAPM TG-43 report9 took the average of these two mea-
surements and applied a multiplicative correction 共1.048兲 to
convert from Solid Water® measurement medium to a liquid
water reference phantom,
D95D共r = 1 cm, ␪ = ␲/2兲
⌳95D,T88S =
SK,T88
= 0.74 cGy · h−1 · U−1 .
The first subscript of ⌳95D,T88S, 95D, refers to the date of the
publication documenting the measured dose rate at 1 cm,
D95D共r = 1 cm, ␪ = ␲ / 2兲, 共in this case, the 1995 TG-43 re-
port兲, while the second subscript, terminating in an “S” for
“strength,” refers to the source calibration standard, to which
the dose rate is assumed to be normalized. Thus, it is as-
sumed that clinical investigators, whose subsequent reports
define the clinical experience supporting 103Pd prostate
brachytherapy, utilized dose-calculation parameters equiva-
lent to those tabulated in the 1995 TG-43 report.
3. Transition from “heavy” to “light” seed design
„1992–1993…
The above-described TLD measurements were performed
using seeds containing low specific activity reactor-produced
103
Pd. These seeds, called “heavy seeds,” were gradually re-
placed with “light seeds,” containing higher specific-activity,
accelerator-produced 103Pd, over a one-year period ending in
early 1993. Each Model 200 seed contains two graphite pel-
lets with palladium metal coatings within which the radioac-
tivity is uniformly distributed. Monroe and Williamson7 ap-
proximated the effect of the heavy-to-light seed
manufacturing process modification on seed geometry by re-
ducing the thickness of this metal coating from 10.5 µm 共260
µg Pd/pellet兲 to 2.2 µm 共57 µg Pd/pellet兲 in their simulations.
Using Monte Carlo techniques, these authors found that the
dose-rate constant 共when normalized to the WAFAC stan-
dard兲 and radial dose function were not significantly affected
by this change. However, the anisotropy constant ␾ ¯ an 关based
on an inverse-square law weighted average of ␾an共r兲 over the
1 to 5 cm distance range兴 was found to be 0.884 and 0.862
for the “heavy” and “light” seed designs, respectively. Mon-
roe and Williamson7 provided a preliminary evaluation of
this effect on 共DTx / DRx兲t ratio using the results of their
Monte Carlo analysis of the Model 200 seed.
Medical Physics, Vol. 32, No. 5, May 2005
125
I interstitial brachytherapy 1428
4. Shift in vendor calibration „Fall 1997…
In contrast to previous 109Cd standard replacements, the
replacement implemented by Theragenics Corporation in
fall, 1997 resulted in a 9.7% decrease in apparent activity
assays relative to SK,T94 共column 4, rows 3 and 4 of Table
IV兲, corresponding to the decrease in Aapp initially observed
by several physicists in 1997. The apparent activities and
nominal air-kerma strengths traceable to this standard are
denoted by Aapp,T97 and SK,T97, respectively. Relative to the
time-weighted 1988–1997 average of the four prior SK,Tnn
standards, S̄K,T88–94, SK,T97 calibration values are 9% smaller:
SK,T97 / S̄K,T88–94 = 0.911. These data indicate that the Ther-
agenics™ assay was essentially constant from 1988 until Fall
1997. In 2000, Theragenics amended their calibration proce-
dure to ensure that their Aapp calibration will be maintained
within ⫾ 2% of its post-1997 level following future 109Cd
source standard replacements.
共2兲 5. Implementation of the NIST WAFAC 1999
standard
Based on measurements performed in 1998 and 1999, a
new SK standard for Model 200 source air-kerma strength,
SK,N99, was established by NIST in 1999 based upon the
WAFAC.2 A difference of more than 23% between Theragen-
ics’ SK,T97 assay and the NIST WAFAC SK,N99 values was
noted. The conversion factor relating the two definitions was
determined to be:
SK,vendor SK,T97
= = 0.767 ± 0.006.
SK,NIST SK,N99
The 共DTx / DRx兲t ratios recommended by the AAPM 2000 re-
port were based upon this value. Theragenics began to issue
calibration certificates traceable to SK,N99 on 20 March, 2000.
6. Revised dosimetry parameters and AAPM 2000
dose-specification guidance „1999–2000…
In preparation for implementing the SK,N99 standard, Ther-
agenics commissioned two dose-rate constant determinations
for the Model 200 source. Using TLD dosimeters in a solid
water phantom, Nath et al.3 reported a dose-rate constant,
⌳00D,N99S, value of 0.65± 0.05 cGy h−1 U−1. Williamson4 re-
ported a value of 0.68± 0.02 cGy h−1 U−1 using Monte Carlo
simulation techniques. Both values were traceable to the
WAFAC standard as implemented in calendar year 1999. The
AAPM 2000 guidance document recommended using an
equally weighted average of these two values yielding
⌳00D,N99S = 0.665± 0.03 cGy h−1 U−1. That report recom-
mended that the relative dosimetry parameters, i.e., radial
dose function and anisotropy constant, given in the 1995
TG-43 report continue to be used. These parameters are des-
ignated by the subscript “00D.”
7. Discovery and correction of calendar year 1999
WAFAC measurement errors „March 2001…
Due to an unresolved anomaly, WAFAC calibrations per-
formed at NIST in calendar year 共CY兲 1999 were systemati-
 TABLE IV. Ratios of administered-to-prescribed dose, 共Dt兲Rx
Tx
, as a function of year t and dosimetry data tD for 103Pd Implants. Bold indicates current analysis, using CIA D90 values. tTG43U1⬎ March 2004 denotes the

1429
Medical Physics, Vol. 32, No. 5, May 2005

date on which the revised TG-43 recommendations were implemented.

Prescription

Williamson et al.: Dose specification for

parameters
Time period 共t兲 Initiating event kkD, yyS
assumed by
SK,t Ⲑ SK,N99 Ⲑ
具D共r៝兲典xref 具D共r៝兲典xRx 共Dt兲Rx
Tx

DxTx DxRx
DRx
t 共Gy兲 共Gy兲

5/88–3/90

4/90–3/93
Heavy seed production 共Cd source #1兲

Heavy seed production 共Cd source #2兲

95D, T88S

95D, T90S
0.877

0.890
0.911 关0.899兴b
1.039 共1.048兲a 关1.079兴b

1.024 共1.048兲a 关1.064兴

其 共Dt兲Rx
Tx
= 1.029 DxTx = 118 Gy
119.4

117.7
115

115

其
4/93–11/93 End of heavy seed era: light seed production begins 共Cd 95D, T90S 0.890 0.989 共1.010兲a 关1.064兴b 113.7 115
source #2兲
0.880 关0.899兴b 共Dt兲Rx
Tx
= 0.990 DxTx = 114 Gy
12/93–6/94 Light seed production 共Cd source #3兲 95D, T93S 0.861 1.022 共1.010兲a 关1.099兴b 117.5 115

7/94–9/22/97 Light seed production 共Cd source #4兲 95D, T94S 0.894 0.984 共1.010兲a 关1.059兴b 113.2 115

9/22/97–3/19/00 SK,T97 standard shifts by 9.7%, 共Cd source #5兲 95D, T97S 0.807 0.880 关0.899兴 b
1.090 共1.102兲 关1.172兴
a b
125 115

103
Pd and
3/20/00–3/4/01 Theragenics replaces SK,T97 with SK,N99 and AAPM 2000 00D, N99S 1.053 0.979 关1.000兴b 0.930 共0.940兲a 关1.000兴b 116 125
dose parameters 00D, N99S accepted

0.957 共0.990兲a

125
3/5/01–tTG43U1 Corrected SK,N99 standard implemented and DRC 01D, N99S 1.00 0.957 120 125

I interstitial brachytherapy
revised

⬎tTG43U1 04D, N99S parameters 04D, N99S 1.00 1.000 1.000 共1.000兲a 125 125
共approved 1D formalism兲

⬎tTG43U1 04D, N99S parameters 04D, N99S 1.00 0.980 共1.000兲a 0.980 共1.000兲 122 125
共old 1D formalism兲
a
Ratios from original Monroe and Williamson paper.
b
Ratios from AAPM 2000 Guidance.

1429
1430 Williamson et al.: Dose specification for 103
Pd and
cally elevated by seed model-dependent factors of up to 7%,
relative to measurements performed before and after this pe-
riod. Many models of 125I and 103Pd sources were unfortu-
nately affected by this anomaly. For the Model 200 source,
the SK,N99 measurements were elevated by 5.3% during this
period 共see Appendix A, Sec. 6, and Appendix B, Sec. 2.3 of
the TG-43 2004 update6兲. Unfortunately, the AAPM 20001
recommendations were based upon these erroneous measure-
ments. This measurement error was corrected by NIST in the
first quarter of 2000.
As with other seed models, PEBD coordinated the transi-
tion to the corrected WAFAC standard with NIST, Theragen-
ics, and the ADCLs on 5 March, 2001. Since each such tran-
sition was vendor- and model-specific, no AAPM report was
published to advise the community and vendors were respon-
sible for communicating the relevant action plan to their cli-
ents. For the Model 200 source, the corrected WAFAC stan-
dard was implemented simultaneously by the vendor, NIST,
and ADCLs on 5 March, 2001 共Appendix A, Sec. 6 of the
TG-43 2004 update6兲. As part of this process, the measured
dose-rate constant of Nath et al.,3 which was normalized to
erroneous WAFAC measurements, was increased by 5.3% to
compensate for the correction. This led to a new revised
average dose-rate constant ⌳01D,N99S = 0.68 cGy h−1 · U−1. At
that time, AAPM advised the community to continue using
the 2000 administered-to-prescribed dose ratios and guid-
ance derived therefrom until further notice. It is assumed that
these recommendations remain operative up to the present
time.
8. Revised dosimetry parameters and the updated
TG-43 protocol „March 2004…
Since implementation of the 2000 AAPM guidance
report,1 the Model 200 dosimetry parameters have been fur-
ther refined. A comprehensive Monte Carlo-based study7 was
published by Monroe and Williamson, which contained
TG-43 dosimetry parameters for both the “light” and
“heavy” seed designs. In addition, Yue and Nath17 published
measured light-seed 2D anisotropy functions which were in
excellent agreement with Monroe’s calculations. Both stud-
ies confirmed that the 1995 TG-439 anisotropy functions,
yielding a ␾ ¯ an,95D = 0.90, significantly overestimated the
source isotropy compared to more recent publications, which
imply ␾ ¯ an,04D = 0.862.
In March 2004, a major update of the TG-43 protocol was
published.6 It contained revised data, designated by the sub-
script “04D,” for the Model 200 seed. The recommended
⌳04D,N99S is nearly identical to ⌳01D,N99S. New radial dose
functions, 1D anisotropy functions, and 2D anisotropy func-
tions 共based on Monroe’s simulations7兲 were recommended
for clinical use. In addition, the dose-calculation formalism
itself was modified. The revised formalism requires use of
the 1D anisotropy function rather than the anisotropy con-
stant, ␾
¯ an,04D and specifies a new method of calculating doses
at small distances. It also advises users to adopt the line-
source geometry function over the point-source function.
Both the new relative “04D” dosimetry parameters and re-
Medical Physics, Vol. 32, No. 5, May 2005
125
I interstitial brachytherapy 1430
vised dose-calculation formalism are used in the analysis to
follow as “reference dosimetry parameters,” i.e., used to es-
timate “administered dose.”
The dose ratios recommended in the AAPM 2000 report1
take into account the developments described in Secs. II A 1,
II A 2, II A 4, II A 5, and II A 6 above. The revised analysis,
presented in the following, takes into account the remaining
phenomena: heavy- versus light-seed design 共Sec. II A 3兲,
1999 WAFAC errors 共Sec. II A 7兲, and dosimetry parameters
and formalism revised as described by the new TG-43 pro-
tocol 共Sec. II A 8兲.
B. Generalized formalism for evaluation of
administered-to-prescribed dose ratios
To evaluate the ratio of administered dose, DTx, to pre-
scribed dose, DRx, the methodology described by Monroe
and Williamson7 has been adopted. Their analysis accounts
for changes in the dose-rate constant used for treatment plan-
ning and time-dependent discrepancies between vendor and
NIST source-strength specifications as does the original
AAPM 2000 analysis. In addition, Monroe and Williamson7
accounted for the dosimetric effect of Model 200 seed inter-
nal geometry changes caused by the transition from the
heavy seed to the light seed production process, the NIST
1999 WAFAC anomaly, and the dose-parameter revisions
published in the 2004 TG43 protocol, none of which were
anticipated by the AAPM 2000 Report.1 The influence of
seed manufacturing process changes on the DTx / DRx ratio
was incorporated into the analysis by introducing separate
time-dependent reference dosimetry parameters for the light
and heavy seeds. The current report adapts the Monroe–
Williamson analysis with the addition of more sophisticated
dose-averaging techniques. In addition, this report consis-
tently uses the 1D dose-calculation formalism recommended
by the 2004 AAPM report6 in contrast to the Monroe–
Williamson analysis which used the old TG43 dose-
calculation formalism.9
The mean administered-to-prescribed dose ratio, 共Dt兲RxTx
, is
冋冓 冔册 冋
given by
共Dt兲Rx
Tx
= t 共r
Dref ៝兲
Dt 共r៝兲
Rx ·
SK,N99 t⬘ ⬎ 3/01
SK,t
册, 共3兲
where t and t⬘ refer to the past time in question and current
time, respectively; 共Dt兲Rx Tx
denotes the administered-to-
prescribed dose ratio for time t, and D共r៝兲 denotes the calcu-
lated dose at position r៝ in an implant. The bracketed quantity,
具X典, denotes the result of spatially averaging the indicated
quantity over the appropriate region within the planning tar-
get volume 共PTV兲 of a typical implant. Various approaches
to spatial averaging are discussed in the following. The quan-
tity Dref ៝兲 denotes the administered dose at location r៝, or
t 共r
dose actually delivered, during the period t as approximated
by the selected reference dosimetry parameters. Reference
parameters are those considered, based upon current knowl-
edge, to provide the most accurate and physically rigorous
method of retrospectively and prospectively calculating dose
in an implant. The quantity DRx ៝兲 denotes the corresponding
t 共r
1431 Williamson et al.: Dose specification for
prescribed dose derived from the dosimetry parameters in
use at time t. The last factor on the right of Eq. 共3兲 is the ratio
of “true” air-kerma strength 共SK,N99 as implemented by Ther-
agenics after March 2001 or as implemented in January 1999
for Model 6711 sources兲 to the source-strength standard, SK,t,
accepted as definitive during the time period t for seeds of
identical physical construction emitting identical quantities
of radiation. Assuming that the new TG-43 report was imple-
mented at time tTG43U1 ⬎ 3 / 04, Eq. 共3兲 can be used to derive
the prescribed dose, DtRx ⬘⬎tTG43U1
, for use with the reference
dosimetry parameters and the current air-kerma strength
standard that ensures that patients will continue to receive
the same delivered dose 共as estimated by retrospective appli-
cation of reference dosimetry parameters兲 as otherwise iden-
tical patients planned with “t-era” dose distributions, source
strength standards, and prescribed
DtTx⬘⬎t 共r៝ 兩 SK,N99 , 04D , DtRx
⬘⬎tTG43U1
兲 = D Tx
t ៝
共r 兩 S K,t , tD , D t 兲.
TG43U1
Hence
Rx
Dt⬘⬎t = 共Dt兲Rx
Tx
· DRx
t ,
TG43U1
where DRx t is the prescribed dose 共in units of Gy兲 and the
arguments to the right of the vertical line indicate the dosi-
metric data and SK standard used for treatment planning used
at time t. Generally, the clinical goal is to reproduce the
clinical outcomes of a previously treated group of patients in
the face of significant dose-calculation and source-strength
standard revisions. Obviously, it is necessary to carefully
match the prescribed dose, dose-calculation formalism and
parameters, and SK standardization procedures to the clinical
experience one is trying to duplicate. In the sections to fol-
low, each factor of Eq. 共3兲, along with its method of evalu-
ation, will be defined.
C. Air-kerma strength standard revisions
The air-kerma strength ratios, SK,t / SK,N99, used in the
analysis of 103Pd seed dosimetry are given by
SK,t
SK,N99
冦
0.886, t 艋 9/97, SK,t = S̄K,T88–94
0.807, 9/97 ⬍ t 艋 3/00, SK,t = SK,T97
= Equation 共6兲 was implemented on a commercial treatment
1.053, 3/00 ⬍ t 艋 3/01, SK,t = SK,N99 in 1999
1.000, t ⬎ 3/01, SK,t = SK,N99 in 2000
These values were based on the ratios given in the AAPM
2000 report1 corrected by the magnitude 共1.053兲 of the 1999
WAFAC measurement anomaly, which resulted in elevated
Model 200 seed calibrations by Theragenics and the ADCLs
during the period 3 / 00⬍ t 艋 3 / 01. For the period 1988 to
September 1997, our analysis uses the SK,t / SK,N99 ratio spe-
cific to each cadmium calibration source actually used 共see
Table IV兲, not the average ratio, S̄K.T88–94 / SK,N99, indicated
by Eq. 共5兲.
Medical Physics, Vol. 32, No. 5, May 2005
103
Pd and 125
I interstitial brachytherapy 1431
D. Reference dosimetry parameters
For the currently available “light” seed, the parameters
recommended by the TG-43 2004 update6 were used. The
radial dose function, gL,04D共r兲, recommended therein was de-
rived from the Monte Carlo study by Monroe and
Williamson.7 The function gL,04D共r兲 was defined over the dis-
tance range 0.1–10 cm and the 1D anisotropy function,
␾an,04D共r兲, over the distance range 0.25 to 10 cm. The rec-
ommended dose rate constant, ⌳04D,N99S, was obtained by
averaging the measured value3 共corrected for the 1999
anomaly in SK,N99兲 with the corresponding Monte Carlo
estimate.7 These data are summarized in Table I.
For the “heavy” seed, the 2004 TG-43 report makes no
recommendations regarding dosimetry parameters. The rela-
tive Monte Carlo data by Monroe and Williamson7 are as-
doses: sumed, an approach consistent with the AAPM consensus
Rx
data-formation methodology. This methodology offers two
choices for estimating the consensus heavy seed dose-rate
共4兲 constant: 共i兲 average the Monroe–Williamson Monte Carlo
value 共⌳02D,N99S
MC
= 0.694兲 with the average of the Chiu–Tsao16
15
and Meigooni measurements 共⌳ ¯ TLD
90D,N99S = 0.650兲 or 共ii兲 re-
ject the experimental measurements as candidate data sets
and use the Monte Carlo value without modification:
⌳04D,N99S = ⌳02D,N99S
MC
= 0.694. Because the Chiu–Tsao and
Meigooni measurements were normalized to source-strength
measurements that are not traceable to the current NIST SK
standard and because these pioneering works do not adhere
to modern standards of experimental dosimetry,6 the AAPM
believes that using the unmodified Monte Carlo dose-rate
constant, i.e., option 共ii兲, provides the least uncertain esti-
mate of the heavy seed reference dose-rate constant consis-
tent with the AAPM consensus-formation methodology.
Reference administered doses were calculated according
to the 1D dose calculation formalism recommended by the
2004 TG-43 report 共Eq. 共11兲兲兴.6 For a single seed, the refer-
t 共r
ence dose rate, Ḋref ៝兲, is given by
៝兲
t 共r
Ḋref
GL共r, ␪0兲
= SK,N99 · ⌳04D,N99S · · gL,04D共r兲 · ␾an,04D共r兲.
GL共r0, ␪0兲
共6兲
planning system 共VariSeed Planning Workstaion, Version
7.1, Varian Medical Corporation, Inc., Palo Alto, CA兲 for
共5兲 permanent seed implants. However, this treatment planning
system, like many others, does not support the implementa-
tion of Eq. 共6兲 since it allows only the point-source geometry
function to be used in its implementation of the 1D TG43
formalism. PEBD notes that this planning system, as well as
many other commercial systems, would have supported
implementation of the allowed but not recommended 1D for-
malism 关Eq. 共10兲 of the 2004 TG-43 protocol, using G P共r兲
rather than GL共r , ␪0兲兴. This option closely approximates Eq.
共6兲 although it is less accurate at small distances, e.g., r
⬍ 1 cm. To implement Eq. 共6兲, it was necessary to “fool” the
1432 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1432

planning system’s algorithm into performing the new calcu-

lations using the older point-source approximation by using ៝兲 = SK,t · ⌳tD,XtS ·
t 共r
ḊRx 冉冊
r0
r
2
¯⬘ .
· gtD共r兲 · ␾ an,tD 共11兲
dummy parameters. Essentially, the anisotropy constant can
be folded into the radial dose function, creating a dummy In the case of the future era t 艌 tTG43U1, ḊRx
t 共r兲 was evaluated
radial dose function, g⬘共r兲. This was accomplished as fol- using Eq. 共7兲, using both the dummy parameters given by
lows: Eqs. 共8兲 and 共10兲, 关the equivalent 1D dose calculation for-

t 共r
Ḋref ៝兲 = SK,N99 · ⌳04D,N99S · 冉冊r0
r
2
¯⬘ ,
· g⬘共r兲 · ␾ an
where the primed quantities denote dummy parameters,
listed in Table II, designed to reproduce the dose rates pre-
dicted by Eq. 共6兲 down to distances of 0.1 cm using the
point-source geometry function and the now-forbidden an-
isotropy constant. Letting rmin be the smallest distance for
which ␾an,04D共r兲 is tabulated, these ratios are selected so as
to force Eq. 共7兲 to agree with the currently recommended
model, Eq. 共6兲, for each of the tabulated data entries.
For the case r 艌 rmin, this leads to the following equiva-
lences:
共7兲
mula, Eq. 共6兲, preferred by the 2004 TG-43 report兴, and the
following parameters: ⌳tD,XtS = ⌳04D,N99S, gtD共r兲 = gL,04D共r兲
¯ ⬘ =␾ ¯⬘
and ␾ an,tD
¯ an,04D, where ␾ 7
an,04D = 0.862. The latter option
is equivalent to using the anisotropy constant-based 1D for-
malism given by Eq. D1 of the 2004 TG-43 report, a formal-
ism widely used in the past but no longer endorsed by the
AAPM. The dosimetric parameters assumed for various eras
are summarized in Table I. This report assumes that 1995
TG-43 compatible parameters were used throughout the era
1988–2000 even though the TG-43 report was published in
1995, the same assumption made by the AAPM 2000 report.1
The 1995 TG-43 report recommendations were based upon
averaging the two measured dose-rate constants published at

g⬘共r兩r 艌 rmin兲 =
GL共r, ␪0兲 ␾an,04D共r兲 r
·
GL共r0, ␪0兲 ␾an,04D共r0兲 r0
冉冊 2
· gL,04D共r兲,
that time.15,16 Those readers who wish to duplicate a particu-
lar institutional implant experience based on pre-1995 im-
plants should confirm that the prescription parameters as-
sumed by this report are reasonable approximations to the
¯ ⬘ = ␾an,04D共r0兲
␾ 共8兲 institution’s dose-calculation procedures.
an

In the case of r ⬍ rmin, we set Eq. 共6兲 to the short-distance

extrapolation formula found in Appendix C of the 2004
TG-43 report:

Ḋ共r៝兲 = SK · ⌳ · 冉 冊
rmin
r
2
·
GL共rmin, ␪0兲
GL共r0, ␪0兲
· gL共r兲 · ␾an共rmin兲.
F. Dose-averaging procedures

Three different approaches to evaluating 具DRx ៝兲典 and

t 共r
共9兲 t 共r
具Dref ៝兲典 were investigated by this report. In ascending order
of complexity, these approaches are called “radial dose func-
This leads to the following dummy parameter definition for
tion equivalence approximation 共RDA兲,” “geometry
r ⬍ rmin:
function-weighted single-seed approximation 共GFSA兲,” and
g⬘共r兩r ⬍ rmin兲 “clinical implant averaging 共CIA兲.” Each of these approaches

=
GL共r0, ␪0兲
·
r0
冉 冊
GL共rmin, ␪0兲 rmin 2
· gL,04D共r兲 ·
␾an,04D共rmin兲
␾an,04D共r0兲
,
will be described in turn.

¯ ⬘ = ␾an,04D共r0兲.
␾ 共10兲
an
1. Radial dose function equivalence approximation
To evaluate the dummy quantities defined by Eqs. 共8兲 and
„RDA…
共10兲, the tabulated 1D anisotropy functions6,7 were interpo-
lated onto the finer radial dose function grid by applying The RDA approach has been used by most administered-
linear interpolation to the quantity r2 · GL共r , ␪0兲 · ␾an,04D共r兲 to-prescribed dose ratio analyses published to date, including
and then converting the result back to ␾an,04D共r兲. This proce- the AAPM 2000 Report1 and the Monroe–Williamson
dure is based upon Williamson’s approximation18 ␾ ¯ an article.7 RDA assumes that Eqs. 共6兲 and 共11兲 yield equivalent
⬇ r2 · GL共r , ␪0兲 · ␾an,04D共r兲. The resultant values of g⬘共r兲 and dose-rate predictions and that gt共r兲 ⬇ g95D共r兲. In addition, it
¯ ⬘ are given in Table II.
␾ ignores other subtleties such as errors arising from mixing
an
G P共r兲 and gL共r兲 data in the same equation. Given these as-
sumptions, mean dose ratio assumes a very simple form:

E. Prescription dosimetry parameters

The prescribed dose-rate distribution, for all times ៝兲,

t 共r
ḊRx
冓 冔t 共r
Dref ៝兲
Dt 共r៝兲
Rx =
共⌳04D,N99S · ␾¯ an,04D兲ref
共⌳tD,XtS · ␾¯ an,t兲Rx
. 共12兲

other than t 艌 tTG43U1, was assumed to have been derived

from the original TG43 point-source dose-calculation for- For the Model 200 seed, using the data from Table I we
malism: obtain

Medical Physics, Vol. 32, No. 5, May 2005

1433 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1433

具DRx ៝兲典
t 共r

= 共⌳ · ␾
¯ an兲Rx
t
具f典G共r兲 = 兺
N

ri艌1 cm
f共ri兲 · G共ri兲 冒兺 N

ri艌1 cm
G共ri兲, 共14兲

冦
0.74 · 0.90 = 共⌳ · ␾
¯ an兲95D,T88S , t 艋 3/00 where 兵ri其i=1
N
denotes the set of radial distances 艌1 cm for
which g共r兲 and ␾an共r兲 are specified; G共ri兲 is the inverse
0.665 · 0.90 = 共⌳ · ␾
¯ an兲00D,N99S , 3/00 ⬍ t 艋 3/01
square-law weighting factor; and f共r兲 is the function to be
=

冓 冔
0.68 · 0.90 = 共⌳ · ␾
¯ an兲01D,N99S , 3/01 ⬍ t 艋 tTG43U1 averaged. The mean-dose ratio is then given by

0.686 · 0.862 = 共⌳ · ␾
¯ an兲04D,N99S , t ⬎ tTG43U1 , t 共r
Dref ៝兲 具Dref
t 共r៝兲典
=
Dt 共r៝兲
Rx
具Dt 共r៝兲典
Rx

⌳04D,N99S具␾an,04D共r兲 · gL,04D共r兲典GL共r兲
= . 共15兲
t 共r
具Dref ៝兲典 = 共⌳ · ␾
¯ an兲Ref ¯ an,t具gt共r兲典共r−2兲
⌳tD,XtS · ␾

再
t

0.694 · 0.884 heavy seed, t 艋 1993
= 共13兲
0.686 · 0.862 light seed, t ⬎ 1993.
This approach is identical to that recommended in 2004
TG-43 report for estimating the now-forbidden anisotropy
constant. It was found that 具f典G共r兲 was quite sensitive to the
兵ri其i=1
N
grid assumed. Hence all averages, both for planned
and reference doses, were based on the choice 兵ri其i=1 N

= 兵1 , 1.5, 2 , 2.5, 3 , 3.5, 4 , 5 cm其.

2. Geometry-function weighted single-seed For the reference dose calculations, GFSA yields the fol-
approximation „GFSA… lowing:
具Dref
t 共r៝兲典 = ⌳04D,N99S具␾an,04D共r兲 · gL,04D共r兲典G 共r兲

再
L
The simple RDA approximation is not consistent with the
2004 TG-43 report guidance, which recommends using the 0.694 · 0.6554 = 0.4548 heavy seed, t 艋 1993
=
1D anisotropy function over the anisotropy constant. Nor 0.686 · 0.6399 = 0.4390 light seed, t ⬎ 1993.
does it account for the differences between g95D共r兲 and
共16兲
g04D共r兲 data recommended by the new report. To accommo-
date these changes, a generalized single-seed averaging pro- Since the prescribed dose distribution is calculated by Eq.
cedure was explored, defined by t 共r
共11兲, then 具DRx ៝兲典 becomes

冦
0.74 · 0.90 · 0.7529 = 0.5014, 95D, t 艋 3/00
0.665 · 0.90 · 0.7529 = 0.4506, 00D, 3/00 ⬍ t 艋 3/01
具DRx ៝兲典
t 共r = ⌳tD,XtS · ␾
¯ an,t具gt共r兲典共r−2兲 = 0.68 · 0.90 · 0.7529 = 0.4608, 01D, 3/01 ⬍ t 艋 tTG43U1 共17兲
0.686 · 0.862 · 7483 = 0.4425, 04Dg P,04D共r兲, t ⬎ tTG43U1
0.686 · 0.862 · 7455 = 0.4408, 04DgL,04D共r兲, t ⬎ tTG43U1 ,

where tTG43U1 艌 3 / 04 denotes the date on which the 2004 103

TG43 recommendations were implemented.
3. Clinical implant averaging
The most accurate and appropriate approach to dose av-
eraging is to implement reference and prescription dose-
calculation models on a brachytherapy treatment planning
system using the geometry from typical clinical implants to
assess the change in typical prescription parameters.19 This
method is referred to as clinical implant averaging 共CIA兲. To
implement CIA, the seed geometry from four typical clinical
103
Pd implants was used. The implants consisted of prostate
target volumes ranging from 22 to 46 cm3, prescribed D90
doses ranging from 76 to 130 Gy, and 40–72 Model 200
Pd seeds implanted with a modified peripheral loading.20
Source positions and the prostate CTV contours were derived
from x-ray CT examinations obtained 30 days following the
implant. The planning system 共VariSeed Planning Worksta-
tion, Version 7.1, Varian Medical Corporation, Inc., Palo
Alto, CA兲 calculated dose on a 共2 ⫻ 2 ⫻ 3兲 mm3 grid using
the “constant 共point model兲” with the option “anisotropic
correction” selected. The dose calculation was repeated using
different dosimetric parameters for the various prescription
and reference dose eras specified above. The source strength
per seed was held constant for each simulation, using the
Sk,N99/seed value assumed for the clinical treatment plan.
Dose calculations were performed using the vendor’s dose-
calculation algorithm described by Eqs. 共7兲 and 共11兲. In the

Medical Physics, Vol. 32, No. 5, May 2005

1434 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1434

FIG. 1. Plots of mean dose ratios, 具Dref ៝兲 / DRx

t 共r ៝兲典 and corresponding standard deviation as a function of reference dose in units of D90 for sample clinical
t 共r
implant No. 1. The means and standard deviations are averages of the calculation-point dose ratios falling in dose bins with widths of approximately 12 Gy.
The right upper and lower left graphs compare the 95D prescription dose parameters and formalism 关Eq. 共11兲兴 to the heavy and light seed reference 共04D兲 dose
parameters, respectively. The upper left graph compares the anisotropy constant prescription formalism 共D1 of 2004 TG-43兲 to the Eq. 共11兲 reference dose
formalism using 04D parameters in both cases.

case of the reference dosimetry calculations, the dummy pa-
rameters summarized in Table II were used, which yields
doses equivalent to Eq. 共6兲.
As our results 共see Sec. III below兲 show that the mean
dose ratio is constant within 1% for doses ranging from
0.25D90 to 1.8D90, D90 and D60 were extracted from the re-
sultant prostate DVHs for the four patients to derive the
mean dose ratios recommended by this report:
evaluated by CIA, on the dose in multiples of D90 for the
implant having the largest volume. For all three primary
comparisons of reference and prescription dosimetry param-
eters 共the others can be obtained by scaling the graphs by the
appropriate dose-rate constant ratio兲, the mean dose ratio is
virtually constant between 0.5D90 and 2D90, which includes
the peripheral layers of the target most relevant to clinical
dose prescription. Figure 2 shows the dependence of the dose

冓 冔 t 共r
Dref ៝兲
Dt 共r៝兲
Rx =
1
兺
4
共DXX,i兲ref,t
4 i=1 共DXX,i兲Rx,t
, 共18兲
ratio on spatial position in the transverse bisecting plane of
the implant. As illustrated by Figs. 1 and 2, at doses below
0.25D90, the mean dose ratio increases. As the commercial
planning system exports dose values as 16 bit integers scaled
where XX denotes either 90% or 60% of the prostate volume,
from zero to the maximum dose, this behavior arises from
and DXX,i represents the corresponding DVH statistic from
integer truncation. The uncertainty introduced by discretiza-
the ith sample implant.
tion of doses is less than 0.2% in the therapeutic dose range.
III. RESULTS Very near the seeds, Figs. 1 and 2 indicate that the dose
103 ratios are much larger and more variable. The
A. Reference-to-prescription dose ratios for Pd
共DXX,i兲ref,t / 共DXX,i兲Rx,t ratios were found to be nearly indepen-
brachytherapy
dent of the implant geometry, i, showing a maximum range
Figure 1 illustrates the dependence of mean dose ratio, as of 0.001 over the four implants for both D60 and D90.

Medical Physics, Vol. 32, No. 5, May 2005

1435 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1435

t 共r
FIG. 2. Plots of the dose ratio, Dref ៝兲 / DRx ៝兲 as a function of position in the transverse 共top兲 and sagittal 共bottom兲 planes bisecting the center of the implanted
t 共r
volume for sample clinical implant No. 1. The 95D prescription dose parameters and formalism 关Eq. 共11兲兴 are compared to the light seed reference 共04D兲 dose
parameters.

Medical Physics, Vol. 32, No. 5, May 2005

1436 Williamson et al.: Dose specification for 103
Pd and
FIG. 3. Plot illustrating the variation of the delivered dose for prescribed doses of 115 and 125 Gy as a function of time for the Model 200 103Pd source. After
2000, delivered doses are plotted for prescribed doses of 115 Gy 共solid line兲 and 125 Gy 共broken line兲. For illustration only, we have assumed tTG43U1
= 7 / 05. For post-tTG43U1 implants, the plot assumes that the AAPM preferred 1D dose-calculation model is used 关Eq. 共6兲兴.
Table III compares the mean reference-to-prescribed dose
ratios for the RDA, GFSA, and CIA averaging methods.
With the exception of one case 共comparison of ␾ ¯ an- and
␾an共r兲-based formalisms using 04D data兲, all estimates agree
within 1.5%. Generally, the RDF approximation overesti-
mates the CIA 具Dref ៝兲 / DRx ៝兲典 value by about 1% while
t 共r t 共r
GFSA results in a 0.5% underestimate. For all cases, the D90
and D60 specification parameters produce virtually identical
CIA estimates. However, in the ␾ ¯ an vs ␾an共r兲 formalism
comparison case, the CIA dose-ratio estimate is 1.6% and
2% smaller than the RDA and GFSA estimates, respectively.
Since the same dosimetry data are used by all three methods,
the difference between GFSA and CIA must arise from the
different formalisms, Eqs. 共6兲 and 共11兲, used in the denomi-
nator and numerator, respectively, of these two methods. The
discrepancy suggests that the r−2 weighting scheme for r
艌 1 cm gives a biased estimate of the average single-seed
calculation distance characteristic of clinical implants. In the
1988–present comparisons, this effect could have been
masked by differences in radial dose function in the prescrip-
tion versus reference eras. While the discrepancies among
these three methods are small in relation to the overall un-
Medical Physics, Vol. 32, No. 5, May 2005
125
I interstitial brachytherapy 1436
certainty of clinical dose calculation, it is prudent to recom-
mend the clinical implant averaging technique for perform-
ing future assessments of this type.
B. Administered-to-prescribed dose ratios
The final 共Dt兲Rx
Tx
ratios recommended in this report, as es-
timated by the CIA technique, are listed in Table IV and
plotted in Fig. 3, along with the corresponding values from
the 2000 AAPM report1 and the Monroe paper.7 In addition,
the time-weighted average 共Dt兲Rx Tx
ratios for the heavy seed
共1988–1993兲 and pre-9/97 light seed 共1993–1997兲 eras are
tabulated. Compared to the 2000 AAPM report, the revised
ratios for the heavy seed and pre-9/97 light seed eras are
3.8% and 7.1% smaller, respectively. Thus, a dose of 115 Gy
prescribed in the periods 1988–1993 and 1993–1997 yields
administered doses of 118 and 114 Gy, respectively, in con-
trast to the average administered dose of 124 Gy estimated
by AAPM in 2000.1 The revised 9 / 97 to 3 / 00 dose ratio is
7% smaller than that recommended by the 2000 Report, re-
sulting in an administered dose of 124 Gy compared to 135
Gy. Using the revised dose ratios recommended by this re-
1437 Williamson et al.: Dose specification for 103
Pd and
port, a prescribed dose of 125 Gy5 delivered during the 3 / 00
to 3 / 01 era 共following WAFAC implementation by Ther-
agenics but preceding correction for the 1999 NIST measure-
ment anomalies兲, corresponds to a delivered dose of 116 Gy,
which is 7% lower than the 2000 Report estimate. Following
Theragenics’ implementation of the corrected SK,N99 standard
and the associated dose-rate constant adjustment in 3 / 01,
this difference was reduced to a 4% underdose, i.e., 125 Gy
prescribed corresponds to a delivery of 120 Gy. The major
causes of these revised ratios are the 5.3% error caused by
the 1999 NIST WAFAC anomaly for the Model 200 source
共which was partially mitigated by the revision of the dose-
rate constant from 0.665 to 0.68兲 and the adoption of revised
2D anisotropy functions, which resulted in a change in an-
isotropy constant from 0.90 to 0.862. These two changes
were first evaluated by Monroe and Williamson7 in 2002, but
neither was anticipated by the 2000 report. For institutions
that implement the revised TG43 formalism, Eq. 共6兲, and
associated dosimetry parameters6 共next-to-last line, Table IV兲
without adjusting the prescribed dose, the delivered dose will
increase by 4%, from 120 to 125 Gy. For those who imple-
ment the revised dosimetry parameters using the old TG43
1-D formalism, Eq. 共11兲, the administered dose will increase
by 1.7%, from 120 to 122 Gy 共last line, Table IV兲.
C. 125
I Model 6711 source
As is the case with palladium, the history of iodine seed
dosimetry is closely related to the history of a single seed
model, the Amersham Model 6711 seed. It is well understood
that the original prescribed dose of 160 Gy, used from 1985
until 1995, was based on dosimetry parameters21 that were
changed by the publication of the 1995 TG-43 report. The
result was to change the prescribed dose to 144 Gy,8 and
from 1995 to the present, most institutions have followed
this change.
The manufacturer of the 6711 seed did not adopt the NIST
1999 air-kerma standard through the transfer of a calibrated
source, but instead mathematically implemented an adjust-
ment of 0.897. Consequently, the NIST measurement
anomaly 共⫹5.1% for the Model 6711 seed兲 of 1999 that af-
fected the vendor calibrations of the Model 200 and many
other source types did not influence Amersham calibrations
of the Model 6711 seed. Therefore, only one transition was
made in the determination of air-kerma strength of this seed;
that of the introduction of the NIST 1999 standard.
It is recognized that the incorrect NIST 1999 standard was
disseminated to the ADCLs, who may have passed it along to
customers, who may then have adjusted the strengths of
seeds delivered to them by the manufacturer, but this is not
known with any certainty. Thus, this possibility is ignored
for this analysis.
For the 6711 seed, ␾an,04D共r兲 is almost constant from 1 to
5 cm, so that the anisotropy constant, ␾ ¯ an,04D, 0.943, was
used in a comparison of delivered doses via the RDA
method. This value is slightly different from the value of
0.93 recommended by the 1995 TG-43 report.9 The differ-
ences among the 83D, 95D, and 04D radial dose functions
Medical Physics, Vol. 32, No. 5, May 2005
125
I interstitial brachytherapy 1437
are not large. The comparison of the RDA and GFSA dose-
rate analyses in Table V shows that these errors influence the
administered-to-prescribed dose ratios by at most 1%.
The 1995 TG-43 report recommended a dose rate constant
of 0.88, which was mathematically modified to 0.98 in 1999,
to accommodate implementation of the 1999 NIST
standard.8 The 2004 TG-43 report further revises this value
to 0.965, which almost exactly compensates for the changes
in ␾
¯ an from 1995 to 2004. As a result, the changes in deliv-
ered dose from the introduction of the Model 6711 seed to
the present have been less than 0.5% and can safely be ig-
nored. These data are summarized in Table V.
IV. DISCUSSION AND CONCLUSIONS
The methodology for analyzing the impact of the imple-
mentation of new dose calculation parameters, formalism,
and changes in source strength calibration standards, pre-
sented here, was developed originally by Dr. Williamson and
Dr. Todor at Virginia Commonwealth University. Later, it
was reviewed, reformulated, and incorporated into this report
by the AAPM PEBD subcommittee. This document was re-
viewed and approved by the AAPM PEBD Subcommittee,
Radiation Therapy Committee, and Science Council. Hence
this report represents the official position of the AAPM on
the recommendations for the impact of the implementation
of 2004 TG-43 update on the dose delivered by interstitial
brachytherapy sources.
For this analysis, we selected four typical prostate im-
plants because the most popular application of interstitial
brachytherapy continues to be organ-confined early stage
prostate cancer. That the doses used in the actual treatment of
the four patients differ from the commonly prescribed mono-
therapy dose of 125 Gy for 103Pd prostate implants does not
impact this analysis, since absolute source strength and dose
do not influence the estimated dose ratios. Of the eight
sources presented in the 2004 TG-43 update, our analysis
considered only the 125I Model 6711 source and 103Pd Model
200 source because the vast majority of papers documenting
the clinical efficacy of permanent prostate brachytherapy,
representing decades of clinical experience, are based upon
these sources. Brachytherapy of prostate cancer has become
the treatment of choice for selected patients because of ex-
cellent rates of local control with minimal treatment related
toxicity. With such a successful therapeutic option, it is criti-
cal that any changes in dose delivery techniques, including
changes in dose calculation parameters and formalism, as
well as procedures used in establishing source strength,
should be analyzed critically in order not to compromise the
therapeutic implant in potentially curable patient popula-
tions. This is the motivation behind this rather densely writ-
ten and complex analysis.
As mentioned earlier, the 1999 NIST anomaly affected
many interstitial brachytherapy sources, some by up to 7%.
Although dose calculations for several source models were
affected by 1999 WAFAC measurement anomalies compa-
rable to or greater than those affecting the Model 200 seed,
these sources are not considered by our analysis. Because
1438 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1438

共Gy兲
these source models were relatively new products, any dose-

160

145

145

145

145
DxRx
delivery errors associated with their use are irrelevant to the
interpretation and duplication of the published and evaluated

144.4 共144.5兲

143.0 共144.7兲

143.0 共144.7兲
clinical experience. As discussed in more detail in Sec. III C

共Gy兲

145

145
DxTx
Model 6711 125I vendor calibrations were not affected by the
1999 SK,N99 measurement anomaly.
Three different methods for evaluating the impact of do-
0.902 共0.903兲a simetry changes on prostate implants were employed. The
0.987 共0.998兲

0.987 共0.998兲

1.000 共1.000兲

1.000 共1.000兲
RDA method is the simplest and the most clear intuitively in
共Dt兲Rx
Tx

that the delivered doses will scale proportionally with the

I implants. Bold indicates current analysis, using GFSA method.

product of dose rate constant and the anisotropy constant

provided the radial dose function is unchanged. Like the
RDA method, the GFSA is also a single source method and
具D共r៝兲典xRx

uses inverse square-law 共approximately兲 to weight the dose

1.006 共1.007兲

0.987 共0.998兲

0.987 共0.998兲

1.000 共1.000兲

1.000 共1.000兲
contributions at different distances. The most comprehensive
Ⲑ

method is the CIA method, which uses typical implant ge-

具D共r៝兲典xref

ometries for averaging the dose contributions from different

distances and from many different sources. The next level
calculational techniques, which can further enhance the
SK,t / SK,N99

evaluation of dosimetric impact, would be to use theoretical

1.000

1.000

1.000

1.000
1.115

models of radiation induced cell killing 共for example, Yue et

al.17兲. At this stage we feel that the CIA model is quite ad-
equate for the analysis presented considering the lack of sen-
¯ an,04D = 0.943

¯ an,04D共r兲 共old

sitivity of these calculation results to the method used. Even

¯ an,83D = 0.87

¯ an,95D = 0.93

¯ an,95D = 0.93

the simplest RDA method using the product of dose rate

constant and anisotropy constant gives results within 2% of
the results from CIA method. Thus, the analysis presented
83D, N85S, g83D共r兲, ⌳83D,N85S = 1.039, ␾

04D, N99S, gL04D共r兲, ⌳04D,N99S = 0.965, ␾

04D,N99S, g P04D共r兲, ⌳04D,N99S = 0.965, ␾

95D, N99S, g95D共r兲, ⌳95D,N99S = 0.98, ␾

95D, N99S, g95D共r兲, ⌳95D,N99S = 0.98, ␾

共approved 1D formalism兲
kkD,yyS assumed by DRx

here is relatively insensitive to the choice of calculational

Prescription parameters
125

technique.
, as a function of year t and dosimetry data tD for

1D formalism兲

Our analysis indicates that the full implementation of

2004 TG-43 report recommendations will have no significant
impact on the 125I dose prescriptions and dose delivered 共less
than 2%兲. However, for 103Pd sources, there will be a sys-
tematic escalation of dose delivered by about 4.2% compared
to current practice unless the prescribed doses are revised
downward from 125 Gy. The radiation oncologist has three
choices: 共1兲 stay with the current dose prescription of 125 Gy
and accept a 4% dose escalation; 共2兲 decrease the prescribed
dose to a round number of 120 Gy which will deliver doses
very close to the current practice; or 共3兲 decrease the pre-
1995 TG-43, 95D parameters and WAFAC SK,N99
Pre-TG-43 dosimetry era, Loftus SK,N85 standard

1999 WAFAC measurement anomaly corrected

scribed dose to 115 Gy, which will restore future delivered

doses to levels characteristic of pre-1997 delivery practices.
TABLE V. Ratios of administered-to-prescribed dose, 共Dt兲Rx
Tx

Of course, radiation oncologists should also consider their

own clinical techniques and experiences in terms of disease
control and toxicity, which depend upon many procedural
and technical details such as the choice of margins around
the tumor volume, the loading pattern, number of needles
04D,N99S, parameters
standard implemented

04D,N99S parameters

used and patient selection for brachytherapy. For the sake of

Current analysis, using RDA method.

consistency at the national level, the AAPM recommends

Initiating event

that the radiation oncology physician community review this

report and make recommendations regarding the need for
prescribed dose revision, if any, similar to the American
Brachytherapy Society recommendations5 published in re-
sponse to the AAPM 2000 guidance.1
Time period, 共t兲

2000–present

Although we have focused on the dose prescription for

1985–1999

1999–2000

⬎ Present

⬎ Present

prostate cancer only, the methods described here are appli-

cable for implants at any other site. However, caution should
be exercised in extrapolating the 具Dref ជ兲 / DRx
t 共r ជ兲典 ratios to
t 共r
a

Medical Physics, Vol. 32, No. 5, May 2005

1439 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy
implants that differ significantly from the geometry of typical
prostate volume implants, e.g., planar implants or eye
plaques. In such cases, it may be prudent to re-evaluate the
t 共r
具Dref ជ兲 / DRx ជ兲典 ratio for the specific implant geometry in
t 共r
question.
Finally, it should be emphasized that the impact of the
adoption of the 2004 AAPM TG-43 report recommendations
is a systematic change that would affect all patients under
treatment if adopted uniformly. Therefore, such systematic
changes, even though they may appear small for an indi-
vidual patient, especially considering the dose inhomogene-
ity within a tumor volume, can have a profound effect on the
efficacy of a treatment regimen. Thus, a careful consideration
of all clinical factors is necessary before making systematic
changes in dose prescription and dose delivered by a
thoughtless adoption of a new dosimetry protocol.
WHOM TO CONTACT FOR FURTHER ASSISTANCE
If you have questions regarding the recommendations of
this report or implementing them in your clinic, please con-
tact the Radiological Physics Center 共RPC兲 at MD Anderson
Cancer Center, Houston, TX at 共713兲 792-3226.
ACKNOWLEDGMENTS
The authors would like to thank Dr. Ty Robin, Dr. Mary
Napolitano, and Joe Rodgers of Theragenics Corporation for
their exceptionally detailed and helpful comments.
Certain commercial equipment, instruments, or materials
are identified in this paper to foster understanding. Such
identification does not imply recommendation or endorse-
ment by the AAPM or the National Institute of Standards and
Technology, nor does it imply that the materials or equip-
ment identified are necessarily the best available for the pur-
pose.
a兲
Electronic mail: jwilliamson@mcvh-vcu.edu
1 18
J. F. Williamson et al., “Recommendations of the American Association
of Physicists in Medicine on 103Pd interstitial source calibration and do-
simetry: Implications for dose specification and prescription,” Med. Phys.
27, 634–642 共2000兲.
2
S. M. Seltzer et al., “New national air-kerma-strength standards for 125I
and 103Pd brachytherapy seeds,” J. Res. Natl. Inst. Stand. Technol. 108,
337–358 共2003兲.
3
R. Nath et al., “Measurement of dose-rate constant for 103Pd seeds with
air kerma strength calibration based upon a primary national standard,”
Med. Phys. 27, 655–658 共2000兲.
4
J. F. Williamson, “Monte Carlo modeling of the transverse-axis dose dis-
Medical Physics, Vol. 32, No. 5, May 2005
1439
tribution of the model 200 103Pd interstitial brachytherapy source,” Med.
Phys. 27, 643–654 共2000兲.
5
D. Beyer et al., “American Brachytherapy Society recommendations for
clinical implementation of NIST-1999 standards for 共103兲palladium
brachytherapy,” Int. J. Radiat. Oncol., Biol., Phys. 47, 273–275 共2000兲.
6
M. J. Rivard et al., “Update of AAPM Task Group No. 43 Report: A
revised AAPM protocol for brachytherapy dose calculations,” Med. Phys.
31, 633–674 共2004兲.
7
J. I. Monroe and J. F. Williamson, “Monte Carlo-aided dosimetry of the
theragenics TheraSeed model 200 103Pd interstitial brachytherapy seed,”
Med. Phys. 29, 609–621 共2002兲.
8
J. F. Williamson et al., “Guidance to users of Nycomed Amersham and
North American Scientific, Inc., I-125 interstitial sources: Dosimetry and
calibration changes: recommendations of the American Association of
Physicists in Medicine Radiation Therapy Committee Ad Hoc Subcom-
mittee on Low-Energy Seed Dosimetry,” Med. Phys. 26, 570–573
共1999兲.
9
R. Nath et al., “Dosimetry of interstitial brachytherapy sources: Recom-
mendations of the AAPM Radiation Therapy Committee Task Group No.
43. American Association of Physicists in Medicine,” Med. Phys. 22,
209–234 共1995兲.
10
B. R. Prestidge et al., “Posttreatment biopsy results following interstitial
brachytherapy in early-stage prostate cancer,” Int. J. Radiat. Oncol., Biol.,
Phys. 37, 31–39 共1997兲.
11
J. Sharkey et al., “Minimally invasive treatment for localized adenocar-
cinoma of the prostate: Review of 1048 patients treated with ultrasound-
guided palladium-103 brachytherapy,” J. Endourol 14, 343–350 共2000兲.
12
T. P. Loftus, “Exposure standardization of Iodine-125 seeds used for
brachytherapy,” J. Res. Natl. Bur. Stand. 89, 295–303 共1984兲.
13
J. F. Williamson et al., “On the use of apparent activity 共Aapp兲 for treat-
ment planning of 125I and 103Pd interstitial brachytherapy sources: Rec-
ommendations of the American Association of Physicists in Medicine
radiation therapy committee subcommittee on low-energy brachytherapy
source dosimetry,” Med. Phys. 26, 2529–2530 共1999兲.
14
M. P. Unterweger et al., “Radionuclide Half-life Measurements 共National
15
Institute of Standards and Technology, Washington, DC, 2003兲.
A. S. Meigooni, S. Sabnis, and R. Nath, “Dosimetry of Palladium-103
brachytherapy sources for permanent implants,” Endocurietherapy/
Hyperthermia Oncology 6, 107–117 共1990兲.
16
S.-T. Chiu-Tsao and L. L. Anderson, “Thermoluminescent dosimetry for
103
Pd seeds 共model 200兲 in solid water phantom,” Med. Phys. 18, 449–
452 共1991兲.
17
N. Yue and R. Nath, “Experimental determination of the anisotropy func-
tion for the model 200 103Pd ‘light seed’ and derivation of the anisotropy
constant based upon the linear quadratic model,” Med. Phys. 29, 1120–
1129 共2002兲.
J. F. Williamson, “Dosimetric characteristics of the DRAXIMAGE model
LS-1 1-125 interstitial brachytherapy source design: A Monte Carlo in-
vestigation,” Med. Phys. 29, 509–521 共2002兲.
19
W. S. Bice, Jr. et al., “Clinical impact of implementing the Recommen-
dations of AAPM Task Group 43 on Permanent Prostate Brachytherapy
Using 125I,” Int. J. Radiat. Oncol., Biol., Phys. 40, 1237–1241 共1998兲.
20
W. M. Butler et al., “Comparison of seed loading approaches in prostate
brachytherapy,” Med. Phys. 27, 381–392 共2000兲.
21
C. C. Ling et al., “Physical Dosimetry of 125I seeds of a new design for
interstitial implant,” Int. J. Radiat. Oncol., Biol., Phys. 9, 1747–1752
共1983兲.