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  • This presentation will introduce the concept of brachytherapy and discuss it as an effective form of radiation therapy. The following slides will demonstrate its significant advantages over other forms of radiotherapy and cancer treatments and its benefits for patients, practitioners and payers. The term ‘brachytherapy’ derives from the Greek word ‘ brachy ’ – meaning ‘short-distance’. The significance of this is obvious when you consider the definition of brachytherapy. Unlike EBRT, which sends beams of ionising radiation through healthy tissues to reach a tumor, brachytherapy enables a radiation dose to be precisely delivered either into or immediately next to a tumor or targeted tissue. It achieves this through the placement of a radioactive source using specially designed applicators and computer-controlled delivery machines. The following slides will look at brachytherapy as a sub-division of radiotherapy, focusing on its clinical applications in everyday practice. Slide Summary: As we will see, treating cancer ‘from the inside, out’ offers many advantages for patients, clinicians and those financing healthcare services. References: Stewart AJ & Jones B. Radiobiologic concepts for brachytherapy. In Devlin PM (Ed). Brachytherapy: Application and techniques. Philadelphia, PA, LWW. 2002.


  • 1. Scherpschieten op de prostaat “ Van handbediend naar automaat” John Lapré Vice-President R&D Nucletron
  • 2. Nucletron is a world-wide player in radiation therapy solutions headquartered in Veenendaal
    • Founded in 1975
    • 125 Million Euro Sales with 15 Million Euro R&D investment
    • 550 employees (180 in Veenendaal) of which 100 in R&D
    • Offices in 20 countries, presence in > 100 countries& Products used in 2,500 clinics worldwide
    • Leader in Brachytherapy with complete solutions offering
    • Independent supplier of external beam treatment planning solutions
  • 3. Nucletron at a glance
  • 4. The Big “Oncology” Picture Biopsy DX Imaging Surgery Chemotherapy Radiation Cancer Patient Imaging Chemotherapy Life-long follow up imaging Radiation could be delivered as External Beam RT or Brachytherapy (LDR, PDR or HDR) Pre-Treatment Imaging Treatment Planning Treatmment Delivery & Imaging Post-Ttreatment Imaging
  • 5. Brachytherapy is a highly focal therapy
      • Derives from the Greek word ‘brachy’ – meaning short-distance
      • Placing a radiation source internally, either into or immediately next to the tumor, allowing precise radiation dose delivery 1
    1. Stewart AJ & Jones B. In Devlin Brachytherapy: Applications and techniques. 2 007. Brachytherapy works ‘ from the inside, out’ External Beam therapy works ‘ from the outside, in’
  • 6. Evolution continues Flexitron 1982 1983 1986 Evolution continues 1975 1994 First µ-processor digital LDR First Brachyplanning PC First cervix ring applicator First µ-processor digital HDR First digital interstitial LDR First digital HDR with dummy First digital PDR First IBU First Intravascular brachy First simultanuous ch selector First locked ovoid applicator First locked to prostate template First AL 3 drive stepping system First dual source Innovation continues 1975 1981 1981 1982 1983 1986 1989 1991 1992 2007 2007 2008 2009 2009
  • 7. Brachytherapy has multiple patient benefits across different tumor sites: today’s focus is on prostate 1. . Pötter R. Radiother Oncol 2009;91:141-146 2. Ferrer M, Suarez JF, Guedea F et al. Int J Radiat Oncol Biol Phys , 2008; 72(2): 421–32. 3. Hoskin PJ & Bownes P, Semin Radiat Oncol 2006;16(4):209-17. 4. Pisansky TM, Gold DG, Furutani KM et al . Mayo Clin Proc 2008;83(12):1364-72. 15 American Brachytherapy Society. 26 Polgar C, Major T, Fodor J, et al. Int J Radiat Oncol Biol Phys 2004;60(4):1173-81. 37 Arthur DW & Vincini, FA. J Clin Oncol 2005;23(8):1726-35. 78 Guix B, Finestres F, Tello J et al . Int J Radiat Oncol Biol Phys 2000; 47:95-102. 9. Musmarcher J . Jnl Clin Oncol 2006 ; 24(18S):15543.
  • 8. Experts support Brachytherapy Prostate BT provides superior PSA control over EBRT in patients with low-risk and selected intermediate-risk prostate cancers. Until the results of randomized studies comparing BT with either EBRT or surgery are available within the next decade, nonrandomized comparative studies can provide the yardstick by which patients and physicians can make informed decisions about which treatment is likely to best suit them. For many, that will be prostate BT. (Vaginal Brachytherapy) VBT is effective in ensuring vaginal control, with fewer gastrointestinal toxic effects than with EBRT. VBT should become the standard of care for women with endometrial cancer of intermediate and high-intermediate risk.
  • 9. Prostate BT can be given as LDR (“seeds”) or HDR
    • LDR: Low Dose Rate with radioactive seeds (Iodine-125) implants
      • Parent method of Brachytherapy
      • Manual to automatic placement
      • Loose seeds (rice kernel)=> stranded seeds
    • HDR: High Dose Rate with one moving source with high activity
      • Needs an afterloader to remotely send the source into the body
      • Iridium-192 (3.5 * 0.6 mm) 370 GBq
  • 10. Nucletron’s Prostate Solution with new 3D integrated realtime ultrasound
  • 11. Off-line MR Image: Fusion with real-time Ultrasound in OR
  • 12. Contouring the tumor
  • 13. Insertion into the prostate
  • 14. Evaluation of the treatment plan
  • 15. SeedSelectron is a robotic seed placement device
    • Adjustment knob
    • Delivery tube
    • Compose element
    • Cartridges and Drive Wire
  • 16. SeedSelectron
    • The seedSelectron performs
      • QA of the seeds
      • Composition of the seed train, seeds & spacers
      • Insertion of the seed train
      • Retraction of the needle
  • 17. Animation of robotic seed placement (SeedSelectron)
  • 18. SeedSelectron in a clinical setting
  • 19. Needles insert ion SeedSelectron setup Treatment Delivery
  • 20. 192 Ir tungsten container HDR treatment requires automated remote afterloading: Microselectron or Flexitron afterloaders
  • 21. Source A Source B Test source HDR: Ir-192 source through the catheters to treat after testing for obstructions in the catheters Test Treat Test Test Treat Test Treat Test Treat Treat 1 2 3 4 5
  • 22. Everyday we are bombarded with COMPLEXITY
  • 23. The Art of Simplicity “ ” Apple believes in one thing – FOCUSED SIMPLICITY . We are a $30B company with less than 30 products. In product design and business strategy, subtraction often adds value . A designer knows he has achieved perfection not when there is nothing more to add, but when there is nothing to take away. - Steve Jobs
  • 24. Our innovations focus on a safe, fast and simple treatment SPEED SIMPLICITY SPECIFICITY Reduce treatment times Remove complex set-up S A F E T Y Improve Patient Outcome Early Detection Advanced diagnosis
  • 25. Single Fraction Monotherapy HDR for prostate cancer First Patient treated Dec 2010
  • 26. Prostate Brachytherapy Evolution
    • From: Fully free manual placement of needles and seeds highly depending on the user’s skills
    • To: Manual placement of needles guided by the software making the treatment less user-dependent
        • HDR automated delivery by afterloader
        • LDR automated seed/spacer placement
    • Next step to automate needle placement under image-guidance
      • Transforming MRI guided robots for biopsy taking into BT needle placing robots (Nijmegen, Utrecht, PMH, Johns Hopkins)
    • Allowing for:
      • Further improvement of optimalization of dose delivery
      • Delivery of radiation where it matters: the tumor
  • 27. There is more........ Fully Robotized Minimal Invasive Bladder Surgery using DaVinci Alysis/Rijnstate Ziekenhuis