SYSTEMS OF INTERSTITIAL

BRACHYTHERAPY and ICRU 58

RAJALAKSHMI.R
06.08.2022

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OVERVIEW:

 Introduction

 Indications of Interstitial Brachytherapy

 Systems of Interstitial Brachytherapy

 Comparison of different systems

 ICRU 58

 Conclusion

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INTRODUCTION :

 Interstitial brachytherapy is a mode of treatment where

sealed radioactive source is directly implanted into the
tumour in a geometric fashion.

RATIONALE :

 Highest dose in centre of tumour

 Rapid dose fall off at periphery

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 Types of Brachytherapy technique

• According to method of • According to dose rate

source loading : – Ultra-low dose rate
– Preloading 0.01-0.3 Gy/hr
– Afterloading
• Manual afterloading
– LDR- 0.4-2 Gy/hr
• Remote afterloading - MDR- 2-12 Gy/hr
– HDR- > 12Gy/hr
• According to type of – PDR
application dose rate as HDR,
– Intracavitary
Dose delivered in pulses
– Interstitial
– Intraluminal – cylinders/ moulds
INDICATIONS OF INTERSTITIAL BRACHYTHERAPY:

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SYSTEMS OF INTERSTITIAL BRACHYTHERAPY :

 Paterson Parker system / Manchester system

 Quimby system

 Paris system

 Memorial nomographs

 Computer methods

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SYSTEMS OF INTERSTITIAL BRACHYTHERAPY:

It denotes a set of rules taking into account-

 source strength

 geometry

 method of application

 AIM - To obtain suitable dose distributions over volume(s) to be

treated

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PATERSON PARKER SYSTEM / MANCHESTER SYSTEM

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 Manchester or Patterson-Parker system
 100 year old system
 used preloaded radium needles
 used precalculated dose tables
 developed to deliver uniform dose to a plane
or volume
 used two types of implants
1. Planar Implant
2. Volume Implant

Can we compare systems for interstitial therapy? Andree Dutreix;

Radiotherapy and Oncology. I3 (1988) I27- I35 Elsevier
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Classification:
Planar and Volume implant

Planar implant:
 Sources implanted in a single plane
 dosimetry specified on a parallel plane 5
mm from source plane

Volume implant:
 some tumours are better implanted using
3D shapes such as sphere, cube and
cylinder.
PLANAR AND VOLUME IMPLANT
RULES OF PLANAR IMPLANT :

 Ratio between amount of radium in the periphery and amount

of radium in the area itself depends on size of implant

 Spacing of needles should not be more than 1 cm from each

other or from the crossing ends.

 If the ends of implant are uncrossed, the effective area of dose

uniformity is reduced. That area is reduced by 10% for every
uncrossed end for table reading purposes.

 In multi-implant planes, the planes should be parallel to each

other

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RULES OF VOLUME IMPLANT :

 The total amount of radium is divided into 8 parts and

distributed for various shapes

 The needles should be placed as uniformly as possible,not more

than 1 cm apart.

 If ends of volume implant are uncrossed, 7.5% is deducted from

volume for uncrossed end for table reading purpose.

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QUIMBY SYSTEM

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 Quimby system
• In 1953
• Rules:
– 1cm spaced
– equal intensity sources
– Central high dose, peripherally low dose
– Crossing needles when required
– Precalculated dose tables

Can we compare systems for interstitial therapy?

Andree Dutreix; Radiotherapy and Oncology.
I3 (1988) I27- I35 Elsevier
PARIS SYSTEM

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PARIS SYSTEM : PRINCIPLES

1. The active sources should be parallel and straight

2. The lines should be equidistant

3. The line or plane on which the mid-points of the sources lie should
be at right angles to the axis of each source

4. The linear activity of the lines should be uniform along the length of
each line and identical for all the lines

5. In any one implant the sources are all separated equally from each
other, BUT from one implant to another the source separation may
be varied. A minimum of 5 mm separation is acceptable for the
smallest volumes, rising to 20 mm for the largest volumes

6. For volume implants, the distribution produced in cross section

(central plane) should be either an equilateral triangle or a square.
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PARIS SYSTEM CALCULATION:
Central plane is defined as a plane perpendicular to the sources,
which is at right angles to the long axis of the sources, and is
situated mid-way along their length.

Dosimetric calculations are based on the distribution of sources

across this central plane.

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BASAL DOSE RATE :

 It is calculated from the

position of the sources in the
central plane.

 It is the minimum dose rate

between a pair or group of
sources.

 Where there are a number of

sources the basal dose rate
for the implant as a whole is
taken as the average of its
component parts

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PARIS SYSTEM CALCULATION :

For volume implants,

the distribution
produced in cross
section (central plane)
should be either an
equilateral triangle or a
square

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Reference dose rate (RD) is defined as being 85 per cent of the
basal dose rate and is the dose rate used for calculating the total
time of the implant

Treatment volume is defined as the volume enclosed by the 85

per cent reference isodose.

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PARIS SYSTEM CALCULATION :

 Dosimetry is calculated on central plane

 We define set of dose points (basal dose points on the central

plane)

 Calculate the dose rate at each basal point.

 Calculate the mean of individual basal point dose rates (known

as basal dose rate)

 Calculate 85% of basal dose rate, known as reference dose rate.

 Calculate the treatment time based on reference dose rate and

the dose required.

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 Computer system
• Rules:
– Source distribution: uniform ,linearly arranged in
parallel planes or cylindrical volumes
– Spaced uniformly (larger spacing:1-1.5cm).
– Crossing needles-not required.
– Active length 30-40% longer than target length
– Hot spots in center
 Comparison of systems
Characteris Manchester/ Quimby system Paris system Computer
tic Paterson Parker system
system
Linear Variable Constant Constant Constant
Strength

Source Planar Implants Uniform Uniform Uniform

Distributio Non uniform
n
Volume implants Uniform Parallel Parallel
Non uniform

Line source Constant Constant Constant Constant

spacing 1cm 1cm (8-15mm) [1-1.5cm]

Crossing Required Required Not Not Required

needles Required
 MUPIT(Martinez Universal Perineal Interstitial
Template)

• Multiple site single template

• Used for cervical, vaginal female urethral,
perineal, prostate and anorectal carcinoma.
• Consists of
– Flat acrylic template and flat acrylic cover
plate(11x8x1cm)

– Acrylic obturator(two sets),screws and

stainless-steel needles.

– vertically 1 cm apart.
– Three large holes are located along the
vertical centre line
- The top - Foley catheter from the urethra
- central and bottom holes for the vaginal
and rectal cyclinders.
– Array of holes - determine the geometry
of source placement with respect to
anatomic structures
• Type I holes:
– Perpendicular to the template
– Only volumes extending 4cm to
either side to be covered
• Type II holes:
– Oblique to the template, angled
13 degree laterally outward.
– Divergent rows allows coverage of
larger volume of parametrium
without hitting the ischium.
– volumes extending outward to
7cm can be covered upto a depth
of 14cm.
• Central hole in Vaginal cylinder
 Workflow
• Patient preparation and applicator insertion
• Image acquisition (eg, CT and/or MR)
• Needle localization and digitization
• Target and OAR delineation
• Dose calculation/optimization
• Pretreatment quality control
• Treatment delivery.
 Patient preparation
• Clinical examination
• CT / MRI
• PAC clearance of the patient
• 2 days prior to the implant: Bowel preparation
– liquid diet from 24 hours prior to the implant
– Tab Gasex 1tab thrice daily for 3 days
– Tab Dulcolax 10mg twice daily for 3 days

1 day prior to implant

– Neotonic enema
– Shave and clean perineum
– Start iv antibiotic Cefazolin 1g BD
– Carry out anesthetic pre op orders
– Nil orally after 10 PM
 PROCEDURE
• On day of implant
– Neotonic enema
– Slow iv fluids started in the morning
• POST OP
– Carefully observe for any bleeding per rectum/hematuria
– Maintain frog leg position
– Maintain continuous infusion of epidural anaesthesia
• IMPLANT REMOVAL
– Needles with template removed
– Apply tincture benzoin at the bleeding points
– Advise perineal sitz baths and vaginal douches 2-3 times 3
hours apart after implant removal
THANK YOU

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