Conventional Brachytherapy In

Carcinoma Cervix
Moderater - Dr Rajeev Jain sir
Presented by - Dr Rajendra Patel
 BRACHYTHERAPY
• Brachytherapy is a type of radiation treatment in
which small, encapsulated radioactive sources are
arranged in a geometric fashion in & around tumor.

• ADV.
– It delivers very high dose of radiation to tumor
– Sparing normal tissue
– Dose delivered in short duration as compared to External
beam RT.
 BRACHYTHERAPY in Cervix
• Brachytherapy plays vital role in treatment of ca cx. & is
mainly applied as an intracavitary procedure in selected
cases complemented by interstitial implants.

• It consists of positioning specially designed applicators

bearing sealed radioactive sources into a body cavity in
close proximity to the target tissue.

• I/C applications are temporary that are left in the patient

for a specified time to deliver prescribed dose.
 WHY I/C BRACHYTHERAPY
• Uterine cx. is ideally suited for I/C
brachytherapy because

– High tolerance of cervix ,uterus & vagina

– It is accessible organ hence Brachytherapy can be
practised with ease.
– The endocervical canal & vaginal vault form a
suitable vehicle to carry rigid applicators with
radioactive sources.
– These applicators can be used with minor
modifications in all pts.
 ADV. OF I/C
BRACHYTHERAPY
• High dose of radiation is delivered in shortest time.
• Cervix receives 20,000 – 25000 cGys.
• Uterus receives 20,000- 30000 cGys
• Vagina receives 10,000 cGys.

such high doses can’t be delivered by any technique of EBRT.

• Best long term control is achieved
• Sharp Fall off of dose and hence less dose to the
normal structure.
• Less late radiation morbidity .
• Preservation of normal anatomy.
• Better sexual functional life.
 HISTOR
YYork physician
1898 : Discovery of Radium by Marie Curie in Paris.
1903 :Margaret Cleaves, a New
described inserting Radium into the
Uterine cavity of a patient with Ca Cervix.
1908 : I/C brachytherapy started in Vienna
1910 :I/C brachytherapy started in Stockholm
1912 : I/C brachytherapy started at Paris.
1930 : Todd & Meredith developed Manchester
system in U.K.
1960s - After loading technique ( Helneski)
1970- Paris System of dosimetry for Interstitial Brachytherapy
evolved
1975-
Remote Control LDR ( Cs-137)
1985-
HDR Introduces( Ir-192 & Co-60) & ICRU-38 Published
- Concept of Volume in place of point introduced
- Joshlin Published data about the discrepancies in point A & B
1990s - Miniaturized stepping source with optimization
 DOSIMETRIC SYSTEMS
• The dosimetric systems were developed when
computer
historical treatment planning and dose computations were not
available

• Term ‘system’ specifies a set of rules for

– Geometrical arrangement of a specific set of radio
isotopes in a specialised applicator

– To obtain suitable dose distributions over the volume to be treated.

– It specifies treatment in terms of the dose, time and administration

– A specified set of tables to allow, reproducible and easy calculation

in most of the encountered clinical scenarios.

– A system ensures safety and is based on clinical experience.

 STOCKHOLM SYSTEM
• Fractionated (2-3 #s) course over a period of one month.
• For a period of 22 hours each.
• Separated by 1-3wks
• This system used
– Intravaginal boxes made up of silver or gold
– The intrauterine tube made up of flexible rubber.
– These were not fixed together
• Unequal loading of Radium
– 30 to 90 mg of Radium was placed inside the uterus
– While 60 - 80 mg were placed inside the vagina
.
• A total dose of 6500 -7100 mg -hrs was prescribed out of
which 4500 mg Ra was contributed by the vaginal
(dose
box. rate-110R/hr)
 PARIS SYSTEM
• Single of Radium for 120hrs (5-
6days)
application
• In this system, almost an equal amount of Radium
was used in the uterus and the vagina.

• The system incorporated

– Two cork colpostats (cylinder) with
Radium in each
13.3mg
– An intrauterine tube of silk rubber with 33.3mg
Radium
• The intrauterine sources contained
radioactive sources, with source strengths in the
three
ratio of 1:1:0.5.
• The colpostats contained sources with the same
strength as the topmost uterine source
• Designed to deliver a dose of 7000 - 8000 mg hrs
over a period of 5days (45R/hr) (5500mg/hr)
 DOSE SPECIFICATION
• Done in mg-hr i.e. Simple mathematicallyproduct of mg
of Radium times the duration (in hours) of the implant.

• It was easy to use.

• The dose prescription was entirely empirical due to the

lack of
– Knowledge about the biological effects of radiation
on the normal tissues and the tumor
– understanding about the dose, dose distribution and
the duration of treatment.

• Only applicable when both tandem & ovoids are

used & sources are loaded in a rigidly prescribed
manner.
 FALLACIE
•
S
Long treatment time, discomfort to the patient
• Dose prescription method was empirical. Both systems
dose in mg-hour.
specified
• Does not give any information about dose distribution.
• When used in conjunction with EBRT, overall radiation treatment
can’t be adequately defined
• Dose specification method lacks the information on
– Source arrangement
– Position of tandem relative to the ovoids
– Packing of the applicators
– Tumour size, and
– Patient anatomy.

• With the use of this dose prescription method dose to

anatomical
important targets could not be quantified adequately.
• Ignored the importance of tolerance of different critical organs to
radiation.
 MANCHESTER SYSTEM
• The Manchester system is one of the oldest
& extensively used systems in the world.
• Developed by Todd & Meredith in 1930 & was
in clinical use by 1932.
• This systemwas initially developed for radium
tubes, but was easily adapted to different
afterloading systems.
 MANCHESTER SYSTEM
• Manchester system was based on following principles:

• To define the treatment in terms of dose to a point. To be

acceptable this point should have following criteria :
– It should be anatomically comparable from patient to patient.
– Should be in a region where the dosage is not highly sensitive to
small alteration in applicator position.
– Should be in position that allows correlation of dose with clinical
effects

• To design a set of applicators and their loading (with a

given amount of radium), which would give the same dose
rate irrespective of the combination of applicators used.

• To formulate a set of rules regarding the activity,

relationship & positioning of the radium sources in the
tandem & vaginal ovoids to achieve desired dose rate.
 POINT
• Todd & A a point in
defined
paracervical triangle where the
Meredith
uterine vessels cross the ureter as
point A.

• Point A is defined as a point 2cm.

lateral to the center of the uterine
canal and 2 cm. superior to the
mucosa of the lateral fornix, in the
plane of the uterus.

• Now point A is defined as a point 2cm

above the distal end of lowest source
in cervical canal & 2cm lat. to centre
of tandem.
 POINT
• A
Although point A is defined in relation to important
anatomic structures, these can’t be visualized on a
radiograph.

• The keel is placed at the external os. It serves as

important reference point as it can be visualized on
radiograph.

• Dose at point A showed a correlation with local

control and the incidence of late normal tissue
toxicity in the pelvis
 POINT A
connect a line through the center of each ovoid or the
lateralmost dwell position in the ring; extend this
line superiorly along the radius of the ovoids (or ring), and
then move an additional 2 cm superior along the tandem.
From this point, extend out 2 cm on each side laterally
on a line perpendicular to the tandem
For tandem and cylinders, begin at the flange or cervical
marking seed and move 2 cm superiorly along the tandem
and then 2 cm laterally.
 POINT B
• Point B is defined 2cm above external os & 5 cm laterally to
midline

• Represents dose to the pelvic wall, obturator L.N.

• The dose at point B is approx. 25 -30% of the dose at point A.

• Dose to point B, depends little on the geometric distribution of

radium, but on the total amount of radium used.
DOSE LIMITING STRUCTURES
• Bladder
• Rectum
• Vaginal mucosa
• Rectovaginal septum
– No more than 40% of total dose at point A could be delivered
safely through the vaginal mucosa.
– The rectal dose should be 80% or less of the dose at point A;
this rectal dose can usually be achieved by careful packing.
 MANCHESTER SYSTEM
• In this system, the dose distributions were not
calculated for individual patients.

• Applications outside the standard variations were

corrected for, but the majority of patients had applicators
in place for a standard time.

• The Manchester system was a time system based on the

use of standard applicators
 APPICATOR IN MANCHESTER
SYSTEM
• Similar to that used in Paris system
• It had a pair of ovoids & an intrauterine
tube
 INTRAUTERINE TUBE
• The intrauterinetube was made up of the thin rubber ( to
prevent excessive dilatation of the cervical canal)

• These tubes were available in three separate lengths

– 2cm

– 4cm

– 6cm

• In order to accommodate 1, 2 or three Radium tubes (2 cm long) in line

I.U.tubes were closed at one end, and had a flange at the other end so
that when packed into position, the uterine tube did not slip out during
the
treatment.
 OVOIDS
• Used in pairs, one in each lateral fornix

• The shape of ovoids mimics the shape of isodose

curves around a Radium tube having "active length" of 1.5
cm.

• The ovoids were designed to be adaptable to the different

vaginal capacity, with diameter of
– 2 cm
– 2.5 cm
– 3 cm

• The largest ovoid are placed in the roomiest vagina in order

to achieve the best lateral dose throw off
 SPACER
• Apart from ovoids &S
I.U.tubes spacers or washers were used

– To maintain the distance between the ovoids

– To help in their fixation

• Spacer was used to give the largest possible separation b/w

the ovoids so that the dose could be carried out as far laterally
as possible.

• It maintained a distance of 1cm b/w the ovoids.

 PACKIN
• Manchester
G
applicators do incorporate rectal
shielding. not

• Hence gauze is packed firmly and carefully

– behind the ovoids,
– anteriorly b/w the ovoids and the base of the bladder,
– and around the applicator tubes down to the level of the introitus

• Packing helps to
– keep the applicators in position
– to reduce dose to bladder and anterior rectal wall.
 RULES
• The point A should receive the same dose rate, irrespective of the
combination of applicators used.
• Not more than one third of the total dose to point A should
be
delivered by the vaginal ovoids. So that tolerance of vagina mucosa is
not exceeded
• Standard or ideal loading is 60-40 i.e. 60% of the dose to point A is
contributed by intrauterine sources while 40% is contributed
by ovoids.
• Total Dose to point A : 8000 R
– Total number of applications : 2
– Total time for each application : 72 hrs
– Total time : 144 hrs
– Dose rate desired : 55.5 R /hour to point A
• Amount of radium to be used was defined in terms of units.
• 1 unit = 2.5 mg of radium filtered by 1 mm platinum.
• The loadings were specified in terms of integral multiples of this unit.
 LOADING PATTERN
• Total dose at point A using different combinations of
U. tube & ovoids :
– Large tube with large ovoid and washer : 57.5 R
– Large tube with large ovoid and spacer: 56.9 R
– Large tube with small ovoid and washer: 57.6 R
– Medium tube with small ovoids and spacer: 57.3 R

• The variations were thus within 1.5% range.

 ICRU SYSTEM
• For reliable and relevant comparison of different
methods and their clinical results ICRU 38 recommends
a common terminology for prescribing recording and
reporting I/C Brachytherapy applications.

• The ICRU recommends a system of dose specification

that relates the dose distribution to the target volume,
instead of the dose to a specific point

• The dose is prescribed as the value of an isodose

surface that just surrounds the target volume.
 ICRU REPORTING
• Description of technique

• Time dose pattern (application duration)

• Description of reference volume

• Dose at reference points

 Description of the Technique
• Minimum information should include the

– orthogonal radiographs of the application.

– Source used (radionuclide, shape and size of source, and filtration)

– applicator type

– Loading pattern

– Simulation of linear source for point or moving sources

– Applicator geometry (rigidity, tandem vaginal uterine

curvature, connection, source geometry, shielding
material)
 DOSE AT REFERENCE POINTS

• The dose to bladder and rectum depends on the

distribution of sources in a given application.

• The maximum dose to bladder and rectum should

be less than 80% of the dose to point A

• The localization of bladder and rectum can be

performed using radiographs taken with contrast
media in the bladder and rectum.
 BLADDER POINT
• ICRU recommends :

o Foley balloon filled with 7

radiopaque fluid and
cm3pulled down against
urethra

• On a lat. radiograph reporting dose at a

point at posterior surface of Foley balloon
on AP line through centre of balloon.

• On AP radiograph, reference point is

taken at the centre of the balloon
 RECTAL POINT
• The dose calculated at a
point
is 5 posterior to
mm
(opacified) cavity
along an AP
vaginal
line
between vaginal sources.
midway

• On the frontal radiograph, this

reference point is taken at the
intersection of (the lower end
of) the intrauterine source
through the plane of the
vaginal sources.
 LYMPHATIC TRAPEZOID
• Lymphatic trapezoid represents
dose at lower Para-aortic ,
common and external iliac L.N.

• A line is from S1-S2

junction
drawn to top of symphysis,
then a line is drawn from middle
of this line to middle of ant.
aspect of L4

• A trapezoid is constructed in a
plane passing through transverse
line in pelvic brim plane and
midpoint of ant. aspect of body
of L4
 PELVIC WALL REFERENCE POINTS
• The wall reference
represents absorbed dose at the distal part
pelvic
of the parametriumpoint,and at the
obturator
L.N.
• Reporting dose at reference points related
to well defined bony structures & L.N.
areas is particularly useful when I/C BT
is combined with EBRT
• On a AP radiograph, pelvic-wall reference
point is located at intersection of following
lines
– a horizontal line tangential to the highest
point of the acetabulum,
– a vertical line tangential to
the inner
aspect of the acetabulum.
• On a lat. radiograph, the highest points of
the right & left acetabulum, in
cranio -
caudal direction, are joined &
lateral
projection of the pelvic-wall reference point
 REFERENCE VOLUME
• Volume encompassed by
reference theisodose, selected and
specified to compare treatments
performed in different centres using
different techniques.

• ICRU recommends reference

volume be taken as the 60-Gy
(43)
isodose surface, resulting from the
addition of dose contributions from
any external-beam whole-pelvis
irradiation and all I/C insertions.
– Height h,
– Width w, and
– Thickness t.
– and their product should be reported
separately
 TREATED VOLUME

• The Treated Volume is the pear and

banana shape volume that received (at least)
the dose and
selected specified by the
oncologist radiation to achieve the
treatment e.g.
purpose
tumour eradication
of the or palliation,
within the limits of acceptable complications
 IRRADIATED VOLUME
• The irradiated volume is the volume,
surrounding the treated volume, encompassed
by a lower isodose to be specified, e.g., 90 –
50% of the dose defining the treated volume.

• Reporting irradiated volumes is useful for

interpretation of side effects outside the treated
volume and for purpose of comparison.
 APPLICATOR
• Applicators are small-caliber tubes that are inserted
into S
body cavities to hold the brachytherapy sources
in clinically defined configurations.

• The applicators include

– A tandem to be inserted into the uterus

• with different lengths that allow for adaptation according to the
individual anatomy (with a fixed uterine flange)

• Angled at varying degrees to the line of the vaginal component

(0°,15°,30°,45° )
• The deliberate angle in the tube draws the uterus, in most patients,
into a central position in the pelvis away from
the pouch of Douglas, the sigmoid colon, and the
anterior rectal wall.

– Two ovoids, to be positioned in the vaginal vault abutting the

 APPLICATOR
• ApplicatorsSused to insert intracavitary sources
in the uterus and vagina included

– Rubber catheters and ovoids developed by French

researchers,
– Metallic tandems and plaques designed in Sweden
– Thin rubber tandems and ovoids of the
Manchester system.
– Fletcher (1953) designed a preloadable colpostat,
which Suit et al. (1963) modified and made after
loading
 APPLICATORS
• IDEAL CHARACTERISTICS of applicators
– It should have a fixed geometry.
– It should be made of rigid material as fixed & rigid applicators attain and
hold better geometry of the insertions
– Lightweight (ideally 50- 60gm but should not be more than 100gm) for
the
patient's comfort
– capable of easy sterilization.
– Applicators should be of inert material that is not adversely affected by
exposure .
– There should be minimal attenuation of radiation by the walls
of the applicators i.e. it should not produce its own
characteristic radiations
– Vaginal ovoids should be perpendicular to the long axis of vagina to avoid
more dose to rectum and bladder.
– I.U. tube should be angulated
 FLATCHER APPICATOR
• Based on Manchester System
• Stainless steel
• Cylindrical ovoid
• Rectal shield
• Preloaded but modified by Suit
for after loading
• Disadvantages
– Presence of shielding lead
to uncertainty in dosimetry.
– Cylindrical caps lead
to non-uniform doses
to vaginal mucosa.
 HENSCHKE APPLICATOR
• Ovoids are hemispherical
shape. in

• Three ovoid diameters

various tandem &
available lengths
are
• The radioactive sources are
placed parallel to the long axis
of the bladder & rectum

• Thus delivering a higher dose

to these organs
 LDR APPLICATOR
• Fixed geometry
applicator
• Desired can be
around
dose area of interest
delivered
• Easy & accurate
dosimetry
• Less rectal because of
obtuse
dose
angle.
• Perineal whichhelps to
maintain
plate geometry of
application
fixed
• Disadv.
– Bladder complications are more as it
receives higher dose due to more
angulation
 MDR/HDR APPLICATOR
• Modern after loading applicator
that mimics classical Manchester
based applicator.

• I.U. tube with lengths

graduated
different in centimeters
(4& 6cm)

• The vaginal ovoids are of ellipsoid

shape (large, medium, small, half)

• These tubes are held together

and their relative positions fixed
by a clamp ensuring an ideal
physical arrangement.
 RING APPLICATOR
• Based on Stockholm technique
• Intrauterine tubes are of
different
lengths & angulations
• Ring available in different
is
diameters (26, 30, 34mm)
• Acrylic caps cover the ring tube to
reduce dose to vaginal mucosa.
• The ring and the intrauterine
tube are fixed to each other with a
screw.
• A rectal retractor helps in pushing
rectum so that it receives less
dose.
• Adv. of ring applicator:
– Fixed geometry
– Interrelationship b/w
ovoids is maintained.
– Customized planning can be done
 IDEAL APPLICATION
• Use tandem that the
patient's
longest anatomy can
accommodate.

• Increasing tandem length

increases
the the point B
parametrium and pelvic lymph (lateral
nodes) contribution relative to the
uterine cavity surface dose

• The radioactivity near the ends of

the long tandem contributes little to
the surface dose (because of
inverse-square law), whereas each
tandem segment makes roughly
equal contributions to points remote
from the applicator.
 IDEAL APPLICATION
• Colpostats/ovoids with largest clinically indicated diameter
should be used to deliver highest tumor dose at depth, for
a given mucosal dose.
• Ascolpostat diameter increases from 2 to 3 cm,
the
vaginal surface dose decreases by 35% relative to the
dose 2 cm from the applicator surface; This is simply a
Consequence of increasing the source-to-surface
distance.
• The geometry of the insertion must prevent
under
dosing around the cervix
• Sufficient dose must be delivered to the Para cervical
areas; and
• Tolerance of vaginal mucosa, bladder and rectum must
be respected.
 IDEAL APPLICATION
• Tandem -1/3 of the way b/w S1
–S2 and the symphysis pubis
• The tandem -midway b/w the
bladder and S1 -S2
• Marker seeds may be placed in
the cervix
• Ovoids should be against the
cervix (marker seeds)
• Tandem should bisect the
ovoids
• The bladder and rectum should
be packed away from the
implant
 IDEAL APPLICATION
• The tandem should be in the midline or
as nearly as possible equidistant from the
lateral pelvic wall

• The vaginal should

symmetrically
colpostats positioned against
cervix in relation to the tandem be
the
• The ovoids should fill the
vaginal
fornices, add caps to increase the size of
the ovoids if necessary
.
• The ovoids should be separated by 0.5 –
1.0 cm, admitting the flange on
the
tandem.

• The axis of the tandem should be central

between the ovoids.
•
 PATIENT PREPARATION

• Pt is anaesthesitized.

• Patient is in lithotomy
position

• Perineal area is
disinfected
 Anesthesi
• a
Potential options include general, spinal or iv
conscious sedation.

• With IV conscious sedation – levator muscle

tightens making application difficult.

• Conscious sedation with Iv fentanyl and midazolam

is preferred in most patients.

• General or spinal anesthesia result in complete

immobilization during insertion and treatment which
may be 2-4 hr
 APPLICATOR CHECK
• Applicator set is check
for integrity and
completeness

• Dilatation of the
cervix with standard
tooling.
 Tandem
placement:
• Uterine sound
• Hegar uterine dilators are used to dilate the os to 6
mm.
• Tandem length is usually 6–8 cm but its
variable from patient to patient.
• For tandems >8 cm, avoid loading/active
source at end to protect small bowel.
• Tandem should be located centrally between the
ovoids on the AP view and bisect the ovoids on
the lateral view.
 PROCEDURE
• Correct length of IU-tube
ovoids
& are selected
• Inserted by one and
attached
one to fixing
mechanism.
• To determine the rectal
on CT or radiograph a radio
wall
opaque marker is inserted
• After insertion of
gauze packing is done
applicator
behind the ovoids to push
rectum and bladder
reducing
away the dose to these
organs
• After procedure orthogonal radiographs are taken
to check applicator geometry.
 Brachytherap
• y
Stage IA (microinvasive) tumors
– Treated with Brachytherapy alone
– LDR dose is approximately 60 Gy in one insertion or
75 to 80 Gy in two insertions to point A
OR
– with HDR an equivalent
dose, with one or two
fractions per week.

• A reasonable target is to
give to Point A
– 65-75 Gy for Stage IA
disease
– 75-85 Gy for IB - IIB
LIMITATIONS OF (2 D)RADIOGRAPHIC
IMAGING
 For determination of target
• point based dosimetry
• point A may overestimate or underestimate the tumor dose based on
3D imaging*
• no optimization:
• tumor coverage relies on tumor volume at time of BT, larger tumors
requiring greater optimization to be adequately covered by the prescribed
isodose line
• Kim et al** found that dose to point A was significantly lower than
the D90 for HR-CTV calculated using 3D image-based optimization

• dose escalation not possible

• *Kim RY, Pareek P. Radiography-based treatment planning compared with computed tomography (CT)-based treatment planning for
intracavitary brachytherapy in cancer of the cervix: analysis of dose-volume histograms. Brachytherapy 2003;2:200–206.
• **Kim H, Beriwal S, Houser C, et al. Dosimetric analysis of 3D image-guided HDR brachytherapy planning for the treatment of
cervical cancer: is point A-based dose prescription still valid in image-guided brachytherapy? Med Dosim 2011;36:166–170.
AIM
to analyze dosimetric outcome of 3D IGBT &compare dose coverage of HRCTV
to traditional Point A dose.
• N=32patients (stage IA2-IIIB cervical cancer) treated with IGBT
• dose: 5.0-6.0 Gy/# ×5 fractions.
• delineation of CTV as per GYN GEC/ESTRO guidelines.
• D90 for HRCTV was 80-85 Gy,
• D2cc of bladder, rectum, and sigmoid was limited to 85 Gy, 75 Gy &75 Gy.
• RESULTS
• The mean D90 for HRCTV was 83.2 ± 4.3 Gy SD significantly higher (p
<0.0001) than mean value of Point A dose (78.6 ± 4.4 Gy).
• The dose levels of the OARs were within acceptable limits
• Dose to Point A was found to be significantly lower than the D90 for HRCTV

• Image-based 3D brachytherapy provides adequate dose coverage to HRCTV,

with acceptable dose to OARs in most patients.
For determination of OAR
Bladder Point

• ICRU bladder point:

• Foley Bulb in the trigone of bladder with7 cc of dilute contrast is used

• only report point estimates.
• wide range of anatomic variations in bladder points along he length of implant
• doses may be different at bladder base & neck, multiple points have to be taken

• ICRU point may underestimate maximum doses to the OAR, in particular

for the bladder
• ICRU bladder volume point does not represent the hottest part of the bladder
that usually falls about 2 cm superior. highest dose often is about 2-4 times the
dose at the bulb
 Rectal point
ICRU rectal point:

• rectal markers is used which tend to lie on posterior wall of rectum while the
anterior wall is at greater risk.
• Stiff markers can move rectum, flimsy ones are difficult to push deep.
• ICRU rectal point doesn’t usually represent the maximum rectal does,
which, again often is 2-4 cm cephalad.
• maximum does is up to 3 times the ICRU point

None of this localizes the superior bowel - an organ very much at risk.
To be continued
Thank you
c A C E R V I X PA R T 5
 Contents

Advances in gynaecological brachytherapy

ABS recommendations for HDR BT
Image guided brachytherapy
Steps in IGBT
Imaging
Limitations of (2 D)radiographic imaging
Volumetric imaging
GEC-ESTRO recommendations for cervical cancer
BT
 ADVANCES IN GYNAECOLOGICAL
BRACHYTHERAPY

Remote after loading HDR BT

Applicator development: Intracavitary (IC),
Interstitial (IS) & IC+IS
In corporation of Newer Imaging Modalities: CT,
MR, PET, etc.
Advances in Treatment Planning Systems
IGBT: Volume Based Brachytherapy
The American Brachytherapy Society (ABS)
Gynaecologic Cervical Cancer Task group has
developed general criteria for the management of
cervical cancer, designed to guide Radiation
Oncologists and assist in making decisions
regarding therapy
Gynaecologic Brachytherapy*
General Inclusion Criteria:
Stage IA1-IA2
1B1:
IB2 - IVA :radically with concurrent chemo radiation
followed by BT
Stage IVB cervical cancer :may be palliative treated with
BT with or without EBRT
Exclusion Criteria: Absolute contraindications to radical
treatment are-
Prior pelvic radiotherapy with brachytherapy
Life expectancy < 6 month
The use of (IMRT) or 3D CRT is not a substitute for
brachytherapy.
*American Brachytherapy society cervical cancer task group
 Timing of BT
All treatment, including EBRT & BT must be completed
within 56 days from initiation.

HDR-BT commences after 45Gy with up to 2 #/week during

the conclusion of EBRT and during the parametrial boost
portion of treatment.
BT may be initiated earlier(but no earlier than approximately
20 Gy), if the physician determines that the applicator placed
at this time point is adequate.

Chemotherapy is not typically given on the days of HDR-BT

American Brachytherapy society cervical cancer task group
 Steps In IGBT

Pre-implant evaluation
Applicator selection & insertion
Imaging
Delineation
Prescription
Treatment planning
Target dose specification
Treatment delivery
American Brachytherapy society cervical cancer task group
 Pre-implant evaluation

patient should have a detailed gynaecologic examination

assess the anatomy, residual tumor & decide brachytherapy
applicator best suited
appropriate medical evaluations and a pre procedure
anaesthesia assessment
instructions on fasting, bowel preparation, and preoperative
testing, including laboratory studies, should be provided
APPLICATOR SELECTION
Intracavitary applicators
Patients with an intact uterus should have a tandem placed;
Interstitial application - recommended for
extensive cervical lesions
extension to the lateral parametrium or pelvic sidewall
lower vaginal extension,
a narrow vaginal apex
os not negotiable
poorly fitting Intracavitary applicators
Both
if patient had a prior supracervical hysterectomy, a short tandem with
interstitial implant can be used
for patients with large, bulky tumors, to enhance coverage of cervix and
reduce the dose to the organs at risk (OAR)
Imaging after applicator insertion
X ray
USG
CT
MRI

When available, the ABS recommends the use of cross-

sectional imaging, such as magnetic resonance imaging
(MRI) or computed tomography (CT), to obtain
measurements of tumour size, volume, and extent of
disease
AIM - to analyze dosimetric outcome of 3D IGBT &compare dose
coverage of HRCTV to traditional Point A dose.
N=32patients (stage IA2-IIIB cervical cancer) treated with IGBT
dose: 5.0-6.0 Gy/# ×5 fractions.
delineation of CTV as per GYN GEC/ESTRO guidelines.
D90 for HRCTV was 80-85 Gy,
D2cc of bladder, rectum, and sigmoid was limited to 85 Gy, 75 Gy &75
Gy.
RESULTS
The mean D90 for HRCTV was 83.2 ± 4.3 Gy SD significantly higher
(p <0.0001) than mean value of Point A dose (78.6 ± 4.4 Gy).
The dose levels of the OARs were within acceptable limits
Dose to Point A was found to be significantly lower than the D90 for
HRCTV
Image-based 3D brachytherapy provides adequate dose coverage
to HRCTV, with acceptable dose to OARs in most patients.
Ultrasound

Can be very useful during tandem insertion

Localizing the cervical canal when obscured by large tumor,
detecting a retroverted uterus before tandem insertion.
Determines uterine width & height
US does not define the target volume as clearly as MRI
Trans-rectal US may assist with interstitial brachytherapy
when other imaging modalities are not available
 VOLUMETRIC 3 D IMAGING
Aim to
1. localize the source positions.
2. Localize the target.
3. Localize the organs at risk.
4. Determine the relationships between all the above
CT SCAN
Plain CT scan is obtained after applicator insertion with 3-5mm cuts

Advantages:-

verifies proper placement of applicator

reasonable estimate of the location of uterus

fairly good for visualizing bladder and rectum.

analyses 3D BT dose distribution

depicts changes in the OAR related to tumour shrinkage & filling status.

3D dose calculations & optimisation possible

OAR dosimetry based on CT is similar to that based on MRI when
optimized similarly*

long experience in treatment planning for EBRT

readily available in radiotherapy departments

*Eskander RN, Scanderbeg D, Saenz CC, et al. Comparison of computed tomography and
magnetic resonance imaging in cervical cancer brachytherapy target and normal tissue
contouring. Int J GynecolCancer 2010;20:47–53
Problems with CT treatment planning

Produce artifact with metallic applicators

Expensive
GTV not identified
Overestimate tumor contours compared to MRI (although
additional width contoured on CT may not be of detriment)
Fails to provide differentiation between the uterus, cervix,
pariuterine tissues so CT-based contouring guidelines
recommend delineating entire cervix and uterus. not provide
sufficient detail of tumor if selected dose escalation is
required,
Problems with CT treatment planning

contouring sigmoid difficult due to lack of contrast

contrast placed in OAR may cause artifact in
contouring wall of organ.
requires moving patient after application from CT
to treatment room: can produce motion artifact that
nullifies the increased accuracy of IGBT
*Viswanathan AN et al. Computed tomography versus magnetic resonance
imaging-based contouring in cervical cancer brachytherapy: results of a
prospective trial and preliminary guidelines for standardized contours. Int J
Radiat Oncol Biol Phys2007;68:491–498
 MRI
ADVANTAGES
multiplaner imaging
excellent soft tissue contrast
better visualisation of tumor & parametrium involvement
differentiate between uterus, cervix, tumor, other pelvic tissues
& OAR
particularly useful in patients with advanced or deeply
infiltrating tumors.
specific signal intensities allow for distinct separation on T1-
and T2 WI cervix (low T1, low T2), parametrium (high T1, high
T2), tumor (low T1, high T2)
regression of cervical tumors can be documented so dose
escalation possible
organ wall may be more clearly visualized for contouring OAR.
 MRI
DISADVANTAGES
requires special applicators. non-ferromagnetic,
metal or plastic/graphite
very expensive
can produce motion artifact
 The criteria for an adequate implant

(regardless of imaging modality used)

The tandem should bisect the ovoids on an AP and lateral image.
On a lateral image, the ovoids should not be displaced inferiorly from
the flange (cervical stop) and should be as symmetrical as possible
(should overlap one another).
The tandem should be approximately one-half to one third the
distance between the symphysis and the sacral promontory,
approximately equidistant between a contrast-filled bladder and
rectum-sigmoid.
The superior tip of the tandem should be located below the sacral
promontory within the pelvis
Radio-opaque packing will be visible on radiographic images and
should be placed anterior and posterior to the ovoids, with no packing
visible superior to the ovoids.
 Brachytherapy Planning
Contouring : Targets and OAR’s
Planning : TPS
Catheter reconstruction
Loading pattern
Optimization (Manual / Inverse)
Plan evaluation
Doses to HR-CTV, GTV (D90, D100, V100 etc…)
Doses to OAR’s ( rectum, bladder, sigmoid 0.1 cc, 1 cc, 2cc)
 DELINEATION
Advances in image guidance for applicator insertion and
treatment planning have resulted in 3D tissue contouring
guidelines (GEC-ESTRO)

After insertion of applicators, the target volumes and

normal-tissue structures are delineated on images in TPS.
The delineation is to be performed at time of each BT
application.

The delineation process is based on clinical examination

at diagnosis and at BT and on a set of sectional images
(preferably MRI T2 weighted) taken at diagnosis and at BT
with applicator in place.
 Gross tumor volume: GTV
Gross tumour volume (diagnosis) (GTVD) :-
includes macroscopic tumour extension at diagnosis
as detected by clinical examination (visualisation and
palpation) and as visualised on MRI:
Gross tumour volume (BT) (GTVB1, GTVB2, GTVB3):-
includes macroscopic tumour extension at time of BT
as detected by clinical examination and as visualised on
MRI:
In patients treated with upfront BT or with BT alone, GTVB
is identical with GTVD.
 Clinical target volume: CTV
HR-CTV :with macroscopic
ds.
includes GTV + whole cervix
+ presumed extracervical
tumour extension+ residual
ds
Pathologic residual tissue(s)
as defined by palpable
indurations and/or grey zones in
parametria, uterine corpus,
vagina or rectum and bladder
are included in HR-CTV.
No safety margin are added.
IR-CTV :represent significant microscopic ds includes
HR-CTV +different safety margins are added (minimal 5
to 15 mm)

LR-CTV :including potential microscopic spread

treated by surgery and/or EBRT
 IRCTV: for limited disease
(tumour size<4cm)
IR-CTV includes HRCTV
different safety margins are added according to
potential spread
5 mm AP limited by bladder or rectum
10 mm cranially into uterine corpus
10 mm caudally below the cervical os into the vagina.
10 mm laterally into both parametria, usually
representing internal third of the parametrium
+ 5 mm if endocervical tumour in BT only
+ 5 mm laterally if lateral macroscopic tumour in BT
only
Schematic diagram for limited disease,
with GTV, high risk CTV and
intermediate risk CTV :coronal and
transversal view
 IR-CTV: for extensive disease
• IR CTV is based on macroscopic tumour at diagnosis
(GTVD) which is superimposed on HR-CTV at time of BT
(ie GTVBT + Cervix + extracervical tissue)taking
original anatomical tumour spread as reference

Margins are added depending on the regression in initial

tumor extent present at diagnosis
Schematic representation for HR and IR CTV lateral
parametrial limits for extensive ds
 IR-CTV extensive disease :safety
margins
Complete remission
IRCTV=HR CTV(red) +
GTVdiagnosis (blue dot)
no safety margin
Partial response: IRCTV
include
HRCTV ie GTV + cervix+
extracervical residual ds (e.g.
parametria)
+GTVdiagnosis(blue dot)
+safety margin of minimum
10 mm added into the
direction of potential spread
(parametria, vagina, uterus)
In case of stable disease
IRCTV include HRCT
+GTVdiagnosis (blue dot)
+safety margin of 10 mm is added to the initial tumour
extension at diagnosis
Planning target volume: PTV
It is assumed that no extra margins are needed neither for
patient related uncertainties (e.g. organ movement) nor for
set up uncertainties.
Therefore, the PTV is identical to the CTV

Contouring of OARS
rectum : began 1 cm above the anus, ended at the sigmoid
flexure, and covered the outer wall of the organ.
sigmoid :begin at the level of the rectosigmoid flexure and
ended at the anterior crossing of the sigmoid by the pubic
symphysis.
bladder contour included the outer wall of the bladder and
ended at the beginning of the urethra.
Purpose: To compare contours and DVH of tumor & OAR
with CT vs. MRI in cervical cancer BT
A standardized approach to contouring on CT (CTStd) was
developed, implemented and compared with the MRI
contours
primary endpoint :assess the feasibility of using these CT-
standardized (CTStd) contours to approximate MRI-based
treatment parameters.
secondary endpoint: to determine whether CT and MRI
provide dosimetrically similar results for the organs at risk
(OARs)
CT Vs MRI CONTOURING
Vishwanathan et al. IJROBP 2007
10 patients (Stage IIA–IIIB)
underwent pelvic EBRT+ CT f/b tandem and ring BT
Planning CT and MRI were performed and contouring carried out
separately,no contrast used in study.
MRI contoured in accordance with the GEC-ESTRO
recommendations
The CT and MRI volumes were fused
CT contours of the HR-CTVCT and IR-CTVCT were adapted
based on the GEC-ESTRO recommendations for MRI.
The GTV could not be defined on CT. Also difficulty delineating the
superior border of cervix and lateral border of parametria (if
involved) and accurate delineation of the OARs
Volumetric and DVH values
A two-sided t test comparing mean values of height, thickness,&
volume showed no significant differences among three.
However, the tumor width was significantly different for HR-
CTVCTStd and compared with MRI values.
difference in width resulted in statistically significant differences in
D100 and D90.
the tumor width was significantly different for IR-
CTVCTStd compared with corresponding MRI values
resulting in statistically significant differences in D100,
and D90
No statistically significant differences in the dose to 0.1 cm3, 1
cm3, and 2 cm3 for the OARs were noted
 RESULTS
CT significantly overestimated the width of the tumor and altered the
D90, D100
OAR DVH were the same
MRI remains standard for contouring

CT contouring results can be

improved by :-
contrast-enhanced imaging
integration of information
obtained from clinical
examination
multiplaner imaging
MRI immediately before
brachytherapy
 Improving CT Contouring

Dilute contrast placed directly into bladder can determine

lateral recesses.
Barium inserted into rectal tube placed with tip in
rectosigmoid provides adequate sigmoid and rectal contrast.
sagittal images with the applicator in place can ensure that superior extent of
cervix encompasses average cervical height of 3 cm
identify uterine vessels, which delineate cervicouterine junction .This allows
demarcation of upper border of cervix and, therefore, could guide contouring
of superior border of HR-CTV.
However, for patients with tumor extension superior to cervix, only MRI
immediately before or at brachytherapy can accurately delineate the superior
border of the HR-CTV
TREATMENT PRESCRIPTION
It should at least include the following items:
 target
 target dose, dose rate
 dose per fraction
 fractionation plan.

Complete description of brachytherapy technique radionuclide; source

type (wire, stepping source); source strength; applicator type; type of
afterloading (manual or remote); description of additional interstitial
needles if any

The treatment plan, including:

a. The dose distribution to the target and
b. The critical organs and their dose limits.
 Treatment planning
Treatment planning and dosimetry should be performed
every time applicators are inserted to assess doses to the
target and normal tissues

 Planning : TPS
 Target dose specification
 OAR specification
 Catheter reconstruction:
 Loading pattern
 dose specification & optimisation method, if applied
Radiotherapy and Oncology 78 (2006)
67–77
www.thegreenjournal.com
3D dose-volume parameters for BT of cervical carcinoma
Defined dose volume parameters for target & OAR
Cumulative dose volume histograms (DVH) are recommended for
evaluation
 Target dose specification for
GTV,HRCTV & IRCTV with their uses
& limitation

Minimum target dose(D100) & D90 :minimum dose

delivered to 100% & 90% of target
Uses:-
D100 and D90: both highly recommended for reporting
can easily be calculated from DVH and converted to EQD2
doses which makes them suitable for plan comparison of
all dose rate techniques.
D100: limitation: extremely sensitive to inaccuracies in
contouring & dose calculation .Due to the steep dose
gradient, small spikes in the
contour cause large déviations in D100.
D90 is less sensitive to these influences and is therefore
considered to be a more stable parameter
V100 :volume receiving 100 % of prescribed dose describes
Uses:-
V100 asses dose coverage to whole target & is 100 % when entire
target covered by prescribed dose

Limitation:-
V100 is based on prescribed physical dose, only relevant
within a specific dose rate and fractionation, cannot be used
for intercomparison purposes, should be applied solely for
intra-patient plan comparison
The intercomparison problem is avoided when BED are used, e.g.
V(60 GyEQD2),V(85 GyEQD2).
For fractionated treatment, however, this parameter is only usable
for evaluation after last fraction, as it uses summed doses of
all #.
Dose volume parameters for OAR
Typical adverse effects from BT such as ulceration, necrosis and
fistulas occur mainly in limited volumes adjacent to applicator
irradiated with high doses (>80 Gy),
whole organ side effects like overall organ inflammation,
fibrosis or telangiectasia occur mainly after whole organ
irradiation with intermediate or high doses (60–70CGy). within
short time periods
When assessing late effects from BT , small organ (wall)
volumes irradiated to a high dose is of major interest.
As there is rapid dose fall-off near the sources, adjacent small
organ (wall) volumes, dose assessment has to refer to one (or
more) defined dose point(s) in these limited volumes.
OAR specification with
volumetric imaging
recommendations suggest three
quantities to characterize the dose
distribution for OAR. .
minimum dose in the most
irradiated tissue volume
adjacent to the applicator (0.1, 1
& 2 cc) is recommended for
recording
D2 cc can be useful during dose
planning and for evaluating
toxicities
D0.1 cc is indicative of the
maximum dose.
 RECOMMENDED DOSE
PRESCRIPTION
TARGET
For HDR: cumulative dose from EBRT +BT
HR-CTV dose: EQD2=85-90Gy
The IR-CTV dose: EQD2=60 Gy.
Target coverage D90 should be equal to 100 % prescribed
dose
OAR
D2cc bladder ≤90 Gy EQD2
D2cc rectum & sigmoid ≤70-75Gy EQD2
Radiotherapy and Oncology (2010)
In IGBT :geometry of the applicator is extracted from patient 3D images
and introduced into TPS
Due to the steep dose gradients, reconstruction errors can lead to
major dose deviations
applicator commissioning and reconstruction methods must be
implemented in order to minimise errors.
Applicator commissioning verifies location of source positions in
relation to applicator
for optimal visualisation of applicator. Para-transverse imaging with
small slice thickness (≤5 mm) is recommended
contouring and reconstruction should be performed in same image
series in order to avoid fusion uncertainties.
Under well-controlled circumstances reconstruction uncertainties are in
general smaller than other brachytherapy uncertainties.
MR imaging criteria have to be fulfilled.
Technical requirements, patient preparation, as well as image
acquisition protocols have to be tailored to the needs of BT
pelvic MRI scanning to be performed prior to radiotherapy
(‘‘Pre-RT-MRI examination’’) and at time of BT (‘‘BT MRI
examination’’) with one MR imager.
Multiplanar (transversal, sagittal, coronal and oblique image
orientation) T2- weighted images obtained with pelvic surface
coils are considered as the golden standard for visualisation of
the tumour & OAR.
Radiotherapy and Oncology (2012)
Thank you
 Radium 226
Half life – 1600 yr
Photon energy – 0.047-2.45
MeV (0.83 avg)
HVL – 12.0mm
Disintegrate to Ra 222+He 4
both are gas
49 gamma rays
Radium sulfate / radium
chloride
0.1-0.2 mm gold foil
Full intensity 0.66 mg/cm
Half intensity 0.33 mg/cm
 55Cesium 137
Half life – 30 year
Photon energy 0.662 MeV
HVL - 5.5
Monoenergetic Gamma emitting
Insoluble powder or ceramic microsphere
Doubly encpsulated in stainless steel needles or tubes
 27 Co - 60
Half life 5.26 year
Photon energy 1.17 & 1.33 MeV
HVL – 11 mm
High specific activity
Encpsulated in platinum iridium or stainless steel wire
 77 Iridium 192
Half life – 73.8 days
Photon energy – 0.136-1.06 (0.38 avg) MeV
HVL – 2.5 mm
Alloy of 30% Ir + 70% Pt flexible wire or nylon ribbons
containing Ir seeds of 3mm long and 0.5mm diameter
 53 Iodine 125
Half life - 59.4 days
Energy -0.028 MeV
HVL – 0.025 mm
Used for permanent implat
Model 6711 contain silver
wire with silver iodide
adsorbed on its surface.
Figure B
Depending upon loading Based on dose rates used
technology LDR - 0.4-2 Gy/ hr
Preloaded – radium tubes Ra 226, Cs 137
Afterloaded MDR - 2-12 Gy/hr
Manual – Cs 137 Cs 137
Remote – Cs 137, Co 60, HDR > 12 Gy/hr
Ir192 Co 60, Ir192
System of implant
dosimetry
 STOCKHOLM SYSTEM
Fractionated (2-3 #s) course over a period of one month.
For a period of 22 hours each.
Separated by 1-3wks
This system used
Intravaginal boxes made up of silver or gold
The intrauterine tube made up of flexible rubber.
These were not fixed together
Unequal loading of Radium
30 to 90 mg of Radium was placed inside the uterus
While 60 - 80 mg were placed inside the vagina.
A total dose of 6500 -7100 mg -hrs was prescribed out of which
4500 mg Ra was contributed by the vaginal box.
dose rate-110R/hr
 PARIS SYSTEM

Single application of Radium for 120hrs (5-6days)

In this system, almost an equal amount of Radium was used in
the uterus and the vagina.
The system incorporated
two cork colpostats (cylinder) with 13.3mg Radium in each and
an intrauterine tube of silk rubber with 33.3mg Radium
The intrauterine sources contained three radioactive sources,
with source strengths in the ratio of 1:1:0.5.
the colpostats contained sources with the same strength as the
topmost uterine source
Designed to deliver a dose of 7000 - 8000 mg hrs over a period
of 5days (45R/hr) (5500mg/hr)
 DOSE SPECIFICATION
Done in mg-hr i.e. simple mathematical product of mg of
Radium times the duration (in hours) of the implant.
It was easy to use.
The dose prescription was entirely empirical due to the lack
of -
knowledge about the biological effects of radiation on the normal
tissues and the tumor
understanding about the dose, dose distribution and the duration of
treatment.
Only applicable when both tandem & ovoids are used &
sources are loaded in a rigidly prescribed manner.
FALLACIES
Long treatment time, discomfort to the patient
Dose prescription method was empirical. Both systems specified dose in
mg-hour.
Does not give any information about dose distribution.
When used in conjunction with EBRT, overall radiation treatment can’t be
adequately defined
Dose specification method lacks the information on
Source arrangement
Position of tandem relative to the ovoids
Packing of the applicators
Tumour size, and
Patient anatomy.
With the use of this dose prescription method dose to important
anatomical targets could not be quantified adequately.
Ignored the importance of tolerance of different critical organs to
radiation.
MANCHESTER SYSTEM

The Manchester system is one of the oldest & extensively

used systems in the world.
Developed by Todd & Meredith in 1930 & was in clinical use
by 1932.
This system was initially developed for radium tubes, but
was easily adapted to different afterloading systems.
From f m khan
 The Paterson-Parker / manchester system

The Paterson-Parker or Manchester system was developed

to deliver uniform dose within +_ 10% to a volume or
plane .
1) Planar Implant
The ratio between the amount of radium in the periphery and the
amount of radium over the area itself depends on the size of the
implant, for example:-
Area Fraction used in
pheriphery

<25 cm2 2/3

25-100 ½

>100 1/3
2) The spacing of the needles should
not be more than 1 cm from each other
or from the crossing ends.
3) If the ends of the implant are
uncrossed (Fig. 15.15B or C), the
effective area of dose uniformity is
reduced.6 The area is, therefore,
reduced by 10% for each uncrossed
end for tablereading purposes.
4) In the case of multiple implant
planes, the radium should be arranged
as in rules 1 to 3, and the planes
should be parallel to each other.
Volume Implants
Some tumors are better implanted using three-dimensional shapes such
as cylinders, spheres, or cuboids.
1. The total amount of radium is divided into eight parts and distributed
as follows for the various shapes.
cylinder is composed of belt, four parts; core, two parts; and each
end, one part.
sphere is made up of shell, six parts, and core, two parts.
cuboid consists of each side, one part; each end, one part; and core,
two parts.
2. The needles should be spaced as uniformly as possible, not more
than 1 cm apart. There should be at least eight needles in the belt and
four in the core.
3. If the ends of the volume implant are uncrossed, 7.5% is deducted
from the volume for the uncrossed end for table-reading purposes.
For a volume implant, the prescribed dose is stated 10% higher than the
minimum dose within the implanted volume.
Figure Example of a volume
implant with one end uncrossed.
The implant has eight needles in the
belt, four in the core (not shown), and
four at one end. Whereas the needles
in the belt and core are 1 mg each, the
crossing needles at the end are 0.5 mg
each, thus satisfying the Paterson-
Parker rule of radium distribution.
The Quimby System
The Quimby system of interstitial implantation is characterized by
a uniform distribution of sources of equal linear activity.
this arrangement of sources results in a nonuniform dose
distribution, higher in the central region of treatment.
For planar implants, the Quimby table gives the milligram-hours
required to produce 1,000 R in the center of the treatment planes,
up to a 3-cm distance from the plane of implant.
The stated dose is thus the maximum dose in the plane of
treatment.
For volume implants, the stated dose is the minimum dose within
the implanted volume.
The original Quimby tables, like the Manchester tables, are based
on an exposure rate constant of 8.4 R-cm2/mg-h instead of the
currently accepted value of 8.25 R-cm2/mg-h.
The Paris System
The Paris system of dosimetry is intended primarily for removable
implants of long line sources, such as 192Ir wires.
The system prescribes wider spacing for longer sources or larger
treatment volumes.
the sources are of uniform linear activity and are implanted in
parallel lines.
In the Paris system the dose specification is based on an isodose
surface, called the reference isodose.
However, in practice, the value of the reference isodose is fixed at
85% of the “basal dose,” which is defined as the average of the
minimum dose between sources.
It has been shown that the reference isodose for a Paris implant
surrounds the implant within a few millimeters, and its value is
approximately equal to 85% of the basal dose.
Determination of basal dose
(BD) in implants using the Paris
system.
A: Line sources implanted in
patterns of (a) single
plane, (b) squares, and (c)
triangles.
B: Isodose curves in central plane
of a volume implant using the
Paris system. The isodose values
are normalized to the average
basal dose, which is given by
1/4(BD1 + BD2 + BD3 + BD4).
 Computer system
The sources of uniform strength are implanted, spaced
uniformly (1.0 to 1.5 cm, with larger spacing for larger-size
implants), and cover the entire target volume.
Active length 30-40% longer than Target length as ends
uncrossed
Treated volume - sufficient safety margins; peripheral
sources implanted on outer surface
Dose specified by isodose surface that surrounds target
Whole planning with help of computers
Isodose curves for a volume implant using two parallel planes
containing five 192Ir line sources per plane.
A. Central cross-sectional plane.
B. Longitudinal plane through middle of implant. Prescription dose
is specified on the 45-cGy/h isodose curve, which just encloses
the implant in the central cross-sectional plane.
THANKS