Presented by : Navneet Kaur

Mamta Tyagi
Parul Sharma
BRACHY: Short distance(Greek)
BRACHYTHERAPY : the treatment of cancer by the insertion of small sealed radioactive sources
which are directly inserted into the tissue and are arranged in a geometric fashion in and around
the tumor.

Depending on
use/radionuclide
position Depending on Depending on
Depending on
Interstital duration of dose rate
loading pattern
irradiation LDR
Intracavitary Preloading
Temporary MDR
Intraluminal Afterloading
Permanent HDR
Intravascular
Surface Mould
CAVITY : hollow space within the body.
INTRACAVITARY BRACHYTHERAPY : involves the insertion of radioactive sources into
natural body cavities e.g. cervix , rectum, antrum etc.
Types of IC Brachytherapy :
 Depending upon loading technology

- preloaded – radium tubes

- afterloaded
manual – Cs137
remote – Cs137 , Co60 , Ir192
 Based on dose rates
1. Low dose rate –LDR
0.4-2Gy/hr (Ra226 , Cs137)
2. Medium dose rate – MDR
2-12 Gy/hr (Cs137)
3. High dose rate – HDR
> 12 Gy/hr (Co60, Ir192)
BASIC S YSTEMS : The Stockholm system (1910 ; Heyman, 1935 ; Walstam, 1954)
The Paris system ( 1919 ; Lenz, 1927 ; Lamarque and Coliez, 1951)
The Manchester system ( Tod and Meredith, 1938 ; Sandler, 1942 ; mod. Tod and
Meredith, 1953 )
 The original brachytherapy techniques evolved using sealed radium sources for the treatment of
uterine cancer.
 Radium tubes (1.5 – 2 cm long, with source strengths 5 to 20 mg of radium and a total Pt filtration of 1
to 2 mm ) were inserted into the uterine canal and the lateral fornices of the vagina .
 The dosimetry systems were based on the concept of milligram hours .
 Tod and Meredith (1953) began to calculate “dose” in roentgen to various sites in the pelvis by
defining a series of points anatomically comparable from patient to patient.
 Limiting dose was not the dose to the critical structures ( bladder , rectum) ,but to the area where the
uterine vessels cross the ureter . This pyramid shaped area was named as ‘Paracervical Triangle‘ .
 The intrauterine rod-shaped applicator is loaded with 58-80 mg of radium
 The vaginal applicator usually consists of a flat box containing 60-80 mg radium
 The two applicators can be fixed , semi fixed or free to each other.
 The vaginal applicator is held against the
cervix and lateral fornices by careful and
systematic packing.
 2-3 applications are given with 3 week
intervals , each application lasting for
27-30 hrs.
 6500-7100 mg.hrs
 Modifications in the Stockholm method ,
using larger amounts of radium , allow for
the treatment times of 10-18 hrs each.
 3 individualized vaginal sources (one in each lateral fornix and one
central in front of cervical 0s), 1 intrauterine source made of 3 radium
tubes (in tandem position)
 Possible variations of the París system include ; 2 vaginal sources (or
only one) in case of a narrow vaginal cavity; only 2 intrauterine radium
tubes (or only one) in case of short uterus .
 The active length of the sources is usually 16 mm, their linear activity
being between 6 and 10 mg per cm, and their strength between 10 and
15 mg of radium.
 The duration of application is 6-8 days ,7200 – 8000 mg.hrs

 The ratio of the total activity of vaginal sources to the total activity of
uterine sources should be 1.
 There is no connection between vaginal and uterine sources.
Point A :
A point at 2 cm lateral to the center of the Point B :
uterine canal and 2 cm from the mucous
membrane of the lateral fornix of the vagina A point 5 cm from the
in the plane of the uterus mid-line and 2 cm up
from the mucous
- a geometric and not an anatomical point, membrane of the
its position can only be defined with lateral fornix.
respect to the applicators in an idealized or
reference geometry This gives a good
indication of the latera
-allows the treatment to be prescribed in spread of the effective
terms of dose rather than milligram hours. dose in addition to the
-dose regarded as the minimum dose on the dose near the pelvic
surface of a large volume of potentially wall near to the
tumor bearing tissue. obturator nodes.
 achieve a constant dose rate at Point A
 standard “dose” to Point A was fixed at 53 R h-1
 total “dose” for two equal fractions was 8000 R delivered in 144 h.
 dose at Point B is between 25% and 30% of the dose at Point A
 Defines the activity in uterine tube and ovoids.

Tubes length uterine tubes ovoids

long (10+10+15) mg Large , 22.5 mg
medium (10+15) mg Medium , 20 mg
short 20 mg Small , 17.5 mg

 defines the number of units of radium to be used in each ovoid and tube size .
a) it relates to the position of the sources
and not to a specific anatomic structure.
b) dose to point A is very sensitive to the
position of the ovoid sources relative to
the tandem sources, which should not be
the determining factor in deciding on
implant duration.
c) depending on the size of the cervix,
point A may lie inside the tumor or
outside the tumor
 the concepts of maximum, mean, median, and modal target absorbed
dose, as defined in ICRU Report 50 are not relevant because of highly non
uniformity in the absorbed dose .
 Steep dose gradient in the vicinity of the sources throughout the target
volume
 specification of the target absorbed dose in terms of the absorbed dose
at specific points, in the vicinity of the sources, is not at all meaningful
 a volume specification is recommended in ICRU Report 38
 the anatomical region of interest is similar for every patient and the
possible variation in the position of the radioactive sources is limited.
 In intracavitary therapy, the dose is maximum
adjacent to the sources and at the center of the
treated volume, and it falls off continuously with
distance from the sources.
 Thus the size of the treatment volume can not be
deduced from isodose pattern rather a dose
level which defines the treatment volume has to
be indicated.
 A pear shaped isodose pattern is observed in
case of brachytherapy in uterine cancer.
 Dose Gradient at the border of treatment volume is similar for both
techniques
 •• The treatment
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When radium tubes were the only radioactive sources used in intracavitary therapy, their strength
was specified in terms of the mass of radium in mg contained ¡n the tube
When artificial radionuclides became available, the sources were first specified in terms of their
actiuity in mCi
Due to the influence of self-absorption and filtration within the source and its sheath the concept of
"apparent activity" was introduced.
The apparent activity of a source was defined as the activity of a point source of the same
radionuclide which would deliver the same exposure rate in air at the same distance from the
center of the actual source.
In order to compare radium substitutes directly with radium itself, sources were specified in
"milligram-radium equivalent"
 The radium equivalent mass of source is the mass of radium filtered by 0.5 mm of
platinum which leads to the same exposure rate as that from the radioactive source of
interest at the same distance.
Later, the strength of a source was specified in terms of its output, i.e., exposure rate at a
reference . The reference exposure rate in milliroentgens per hour at 1 meter was used
(mR.h-1 .m2).
Recently, the Trancai Committe for the measurement of ionizing radiations (CFMRI, 1983)
has recommended that radioactive sources be specified ¡n terms of “ reference air kerma
rate”.
The reference air kerma rate of a source is the kerma rate to in air, at a reference
distance of one metre, corrected for air attenuation and scattering.
This quantity is expressed in microgray per hour at 1 m
Technique should be described on the basis of given
guidance in ICRU 38 .
The Source
1. Radionuclide
2. Reference air kerma rate
3. Shape , filtration etc.
When a linear source is simulated by a set of point sources
 Activity
 Separations
When moving sources are used to simulate a set of different sources in fixed position
 Type of movement (continuous or stepwise, step distance)
 unidirectional or oscillating movement
 range of movement or oscillation
 speed in different sections of the applicator, or dwell times of the source at different positions
It is recommended that the applicator be described, including the name of the
manufacturer. The description should include information on :
 rigid (or not), consequently with fixed known geometry (or not) of the complete applicator
 rigid uterine source with fixed curvature (or not),
 connection between vaginal and uterine applicators, i.e., fixed, loose (semi-fixed), free
 type of vaginal sources, number and orientation of line sources, special sources (box, ring, etc.)
 high atomic number shielding materials in vaginal applicator (or not)
 RECOMMENDATIONS FOR REPORTING

Total Reference Air Kerma Rate :

The sum of the products of the reference air kerma rate and the duration of application
for each source. This quantity is recommended for specification of sources in
brachytherapy because
o It is proportional to the integral dose to the patient .

o can serve as a useful index for radiation protection of personnel.

o the inverse square law applied to the total reference air kerma which allows evaluation
of the absorbed dose delivered during treatment at distances from the sources down to
20-10 cm
Disadvantage : does not approximate the absorbed dose in the immediate vicinity of
the sources i.e., in the tumor or target volume.
 Dose level :
An absorbed dose level of 60 Gy is widely accepted as the appropriate reference level for
classical low dose-rate therapy .
When intracavitary therapy is combined with external beam therapy, the isodose level to be
considered is the difference between 60 Gy and the dose delivered at the same location by external
beam therapy
Although combined dose does not necessarily produce the same effect as a similar dose from
intracavitary therapy alone
 When uterine sources and vaginal sources are combined , the tissue volume to be described
presents a pear shape with longitudinal axis of this shape coincides with intrauterine source.

o the height (dh) is the maximum

dimension along the intrauterine
source and is measured in the
oblique frontal plane containing
the intrauterine Source.
o the width (dw) is the maximum
dimension perpendicular to the
intrauterine source and is
measured in the same oblique
frontal plane.
o the thickness (dt) is the "maximum
dimension perpendicular to the
intrauterine source and is
measured in the oblique sagittal
Reference Points Close to the Sources and Related to the
Sources :
At points which are located in a region where the dose gradient is high any
inaccuracy in the determination of the distance results in large uncertainties in the
absorbed dose.
Calculation of absorbed dose is not recommended at these points.
 The determination and specifícation of the absorbed dose to organs at risk are useful with respect to
normal tissue tolerance limits.
1) Calculated values : Reference points for the expression of the absorbed dose to the bladder and
the absorbed dose to the rectum have been proposed by Chassagne and Horiot (1977).

Bladder reference point: Rectal reference point :

• Foley catheter is used
• On the lateral
• Balloon is filled with 7cm3 radiograph , an
radio-opaque fluid. anterioposterior line is
drawn from the lower
• Catheter is pulled downwards end of intrauterine
to bring the balloon against source.
urethra.
• The point is located on
• On lateral radiograph, an this line 5mm behind the
anterio-posterior line is drawn posterior vaginal wall.
through the center of balloon &
2) Monitoring of the absorbed dose rate to the rectum :
An alternative to calculating the rectal dose is to measure the dose, or dose rate, at
different points along the anterior rectal wall to ensure that no área of the rectal mucosa
receives a dose above the tolerance level.
The lymphatic trapezoid :
These points correspond to the
paraaortic and iliac nodes
The Pelvic wall reference point :
On the anteroposterior radiograph,
the pelvic wall points are located at
the intersection of a horizontal
tangent to superior aspect of the
acetabulum and a vertical line
touching the medial aspect of the
acetabulum.
On the lateral view, these points are
marked as the highest middistance
points of the right and left
acetabulums
 Dose distribution should be computed for minimum 2 planes : oblique frontal plane and oblique
sagittal plane.
 In 3D planning dose distributions can be calculated in additional sets of planes in order to
determine the absorbed dose at any relevant anatomical points.
This information will provide
 the possibility of comparing the methods of specification used in different centers and of
evaluating their respective merits.
 the possibility of comparing the methods of specification used in historical series (mg-h, points
"A“ and "B") with the methods recommended in the present Report.
 the possibility of deriving new clinical and radiobiological data and correlations which could
improve treatment techniques and develop further the method of specification.
 One linear source only :
- In case of narrow vagina with a uterine source protruding into the vaginal cavity.
- In the case of vaginal irradiation with a central source from a cylindrical applicator.
Thickness (dt) = Width (dw)
 Vaginal source only :
- dw is the largest dimension from right to left in an oblique frontal plane through the main axis of
vagina .
- dt is the largest dimension in the direction perpendicular to the oblique frontal plane.
- dh is measured along the vaginal axis and is commonly shorter than the other two dimensions.
 Rigid Applicator :

- Provided that there is a fixed connection between vaginal and uterine sources, pre-calculated
isodose surfaces can be obtained for given loadings of the applicator.
- Therefore, pre-calculated dimensions of height , width and thickness can be-given.
 Uterine packing :

- width and thickness are usually located at the level of the uterine fundus (the pear-shaped
volume is reversed) .
- height should be determined in the oblique frontal plane, which gives the máximum dimension .