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physics and clinical aspects of interstitial brachytherapy

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physics and clinical aspects of interstitial brachytherapy

  1. 1. PHYSICS AND CLINICAL ASPECTS OF INTERSTITIAL BRACHYTHERAPY PRESENTED BY Dr. Vimoj J. Nair Junior Resident Department of Radiation Oncology PGIMS, Rohtak, Harayana. Moderated By Dr. Vivek Kaushal Professor & Head DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  2. 2. INTERSTITIAL BRACHYTHERAPY <ul><li>Mode of treatment where radioactive sources are directly implanted into tissues in and around the malignant growth. </li></ul><ul><li>Very high dose immediately surrounding the sources with rapid fall off outside. </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  3. 3. INTERSTITIAL BRACHYTHERAPY RESIDENTS’ CONCEPT!!!! DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA OUCH!!!
  4. 4. GENERAL INDICATIONS OF INTERSTITIAL BRACHYTHERAPY <ul><li>Primary Radical treatment </li></ul><ul><ul><li>Well localized where adjacent LN involvement risk negligible </li></ul></ul><ul><li>Implant boost after previous EBRT </li></ul><ul><ul><li>Risk of adjacent LN inv+ </li></ul></ul><ul><li>Perioperative implant </li></ul><ul><ul><li>At site risk of recurrence </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  5. 5. CONTRAINDICATION <ul><li>Target volume not identifiable/ margins indistinct </li></ul><ul><li>Tumor very extensive or with bone involvement </li></ul><ul><ul><li>Poorly tolerated/ bone necrosis </li></ul></ul><ul><li>Tumor access difficult </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  6. 6. ISOTOPES USED FOR INTERSTITIAL BRACHYTHERAPY <ul><li>Radium-226 </li></ul><ul><li>Co 60 </li></ul><ul><li>Cesium-137 [Cs 137 ] </li></ul><ul><li>Gold-198 [Au 198 ] </li></ul><ul><li>Iodine-125 [I 125 ] </li></ul><ul><li>Cesium -131 [Cs 131 ] </li></ul><ul><li>Iridium-192 </li></ul><ul><li>Palladium-103 [Pd 103 ] </li></ul><ul><li>Samarium-145 [Sm 145 ] </li></ul><ul><li>Ytterbium-169 </li></ul><ul><li>Californium-252 [Cf 252 ] </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  7. 7. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Planning: Dose Rates (ICRU #38) <ul><li>Low dose rate (LDR) - 0.4 to 2.0 Gy/hr </li></ul><ul><li>Medium dose rate (MDR) - 2 - 12 Gy/hr </li></ul><ul><li>High dose rate (HDR) - >12 Gy/hr </li></ul>
  8. 8. TYPE OF IMPLANTS <ul><li>TEMPORARY IMPLANT:- </li></ul><ul><ul><li>Short period of dose delivery </li></ul></ul><ul><ul><li>Sources removed after prescribed dose reached </li></ul></ul><ul><li>PERMANENT IMPLANT :- </li></ul><ul><ul><li>For less accessible sites </li></ul></ul><ul><ul><li>Dose delivered over lifetime of source until complete decay </li></ul></ul><ul><ul><li>Sources with short half life: 198-Au seeds ,125-I, 103-Pd seed for prostate implants </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  9. 9. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA AL- ACTIVE LENGTH PL- PHYSICAL LENGTH When target Volume Involves skin & mucosa DIFFERENT TYPES OF SOURCES IN BRACHYTHERAPY
  10. 10. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Interstitial applicators- CATHETERS Interstitial applicators- NEEDLES
  11. 11. INTERSTITAL APPLICATORS DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA GUIDE-GUTTERS - hollow metallic needles consisting of 2 vertical limbs joined by a horizontal flange [First one loaded with hair pin] WIRE + HAIR PIN + CATH- ETHERS
  12. 12. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA TARGET VOLUME SPECIFICATION <ul><li>Define target volume </li></ul><ul><ul><li>Tumor plus margin </li></ul></ul><ul><ul><li>Organ plus risk margin </li></ul></ul><ul><ul><li>Tumor bed </li></ul></ul><ul><li>Methods: </li></ul><ul><ul><li>Orthogonal radiograph </li></ul></ul><ul><ul><li>CT Scan </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>Surgical clips on margin </li></ul></ul>
  13. 13. HOW TO SHOOT?? DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  14. 14. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA SOURCE KEPT AT EQUAL DISTANCE FROM EACH OTHER! NO RULES!!! RESULT - BAD HOMOGENEITY!! HOW TO IMPLANT? INITIAL STRATEGY!! TUMOR RADIOACTIVE SOURCES
  15. 15. <ul><li>Manual methods </li></ul><ul><ul><li>Manchester /Paterson-Parker system </li></ul></ul><ul><ul><li>Quimby systems </li></ul></ul><ul><ul><li>Memorial nomographs </li></ul></ul><ul><ul><li>Paris system </li></ul></ul><ul><li>Computer methods </li></ul>SYSTEMS OF INTERSTITIAL BRACHYTHERAPY DOSIMETRIC PLANNING DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA TEMPORARY INTERSTITIAL
  16. 16. Interstitial implant system consists of <ul><li>Distribution rules </li></ul><ul><li>Dose specification and implant optimisation criteria </li></ul><ul><li>Dose calculation aids(tables etc) </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA HOW TO PUT IMPLANTS WHERE & HOW TO PRESCRIBE DOSE OPTIMALLY
  17. 17. PATERSON-PARKER/ MANCHESTER SYSTEM <ul><li>“ RADIUM ” dosage system to deliver uniform dose (within ±10%) to a plane or volume of interest </li></ul><ul><li>Sources distributed non-uniformly following certain rules, based on the size of the target volume, with more source strength concentrated in the periphery . </li></ul><ul><li>Pre-calculated tables gives cumulated source strength per unit dose (in mgh per 1000cGy) for given implant area or volume. </li></ul><ul><li>To obtain the total source strength, the table value is multiplied by the desired dose rate. </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  18. 18. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Single, Double and Multiple Plane Implants SINGLE PLANE IMPLANTS - <1 cm thick <ul><li>DOUBLE PLANE </li></ul><ul><li>1-2 cm thick </li></ul><ul><li>Required total source strength is equally divided between the two planes, </li></ul>MULTIPLE PLANE - >2 cm thick ALSO VOLUME IMPLANTS
  19. 19. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA VOLUME IMPLANT [CUBE] VOLUME IMPLANT CYLINDER VOLUME IMPLANT SPHERE SINGLE PLANE IMPLANT DOUBLE PLANE IMPLANT
  20. 20. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Eg- FOR 4 X 4 IMPLANT ELONGATION CORRECTION
  21. 21. PATERSON-PARKER/ MANCHESTER SYSTEM [contd] <ul><li>The dose derived from the table values is called the STATED DOSE </li></ul><ul><li>Stated dose is 10% larger than the minimum dose and 10% less than the maximum dose [ UNIFORMITY CRITERION] in the treatment region. </li></ul><ul><li>Treatment regions </li></ul><ul><ul><li>PLANAR IMPLANTS </li></ul></ul><ul><ul><ul><li>plane directly opposite the source plane at 0.5cm distance </li></ul></ul></ul><ul><ul><li>VOLUME IMPLANTS </li></ul></ul><ul><ul><ul><li>volume enclosed by peripheral sources in case of volume implants </li></ul></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  22. 22. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Arrangement of Needles for Planar Implants Shaded areas for dose calculations [implant volume] Active length crossed ends uncrossed ends
  23. 23. DISTRIBUTION RULES FOR PLANAR IMPLANTS <ul><li>Radium amount in Periphery : Centre depends on implant size. </li></ul><ul><li>Needle Spacing not >1cm from each other or from the crossing ends </li></ul><ul><li>If implant ends are UNCROSSED , the effective area of dose uniformity is reduced 10% for each uncrossed end for table reading purposes. </li></ul><ul><ul><li>If UNABLE to cross an end, increase implant size using longer needles to cover the tumor. </li></ul></ul><ul><li>Multiple implant planes- the radium should be arranged as in rules 1-3 and planes should be parallel to each other. </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA AREA ( Sq.CM ) ACTIVITY PERIPHERY INSIDE < 25 2 / 3 1 / 3 25 – 100 1 / 2 1 / 2 > 100 1 / 3 2 / 3
  24. 24. VOLUME IMPLANTS – DISTRIBUTION RULES <ul><li>Total amount of radium divided into 8 parts and distributed as follows for various shapes [Sphere, cylinder, cube] </li></ul><ul><ul><li>CYLINDER: belt , four parts; core , two parts, each end one part </li></ul></ul><ul><ul><li>SPHERE: shell , six parts; core , two parts </li></ul></ul><ul><ul><li>CUBE: each side , one part; core , two parts </li></ul></ul><ul><li>Needles spaced as uniformly as possible, not >1 cm apart. There should be atleast 8 needles in belt and four in core. </li></ul><ul><li>Uncrossed ends – 7.5% is deducted from the volume for table reading purposes. </li></ul><ul><li>For a volume implant the prescribed dose is stated 10% higher than the minimum dose within the implanted volume. </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  25. 25. CORRECTIONS TO BE MADE TO DOSE FROM PP TABLES FOR <ul><li>EXPOSURE RATE CONSTANT ( г ); the tables assume 8.4Rcm2/mg-h instead of the current value of 8.25 cm2/mg-h </li></ul><ul><li>ROENTGEN:CGY FACTOR of 0.957 should be used to convert exposure into dose in muscle. </li></ul><ul><li>OBLIQUE FILTERATION: by the platinum capsule (2-4% error ) </li></ul><ul><li>TISSUE ATTENUATION AND SCATTERING - PP tables are based on exposure in air. </li></ul><ul><li>Thus the mg-h/ 1000R in the original Paterson-Parker tables should be considered equivalent to mg-h/900cGy . </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  26. 26. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA 1 cm spaced, Variable intensity sources non uniformly, more source strength in periphery . CROSSING NEEDLES WHEN REQUIRED UNIFORM DOSE DISTRIBUTION From TABLES – mg-h/900R 1 cm distance 0.66 & 0.33 mgRa/cm sources AREA( Sq.CM ) ACTIVITY PERIPHERY INSIDE. < 25 2 / 3 1 / 3 25 – 100 1 / 2 1 / 2 > 100 1 / 3 2 / 3
  27. 27. QUIMBY SYSTEM <ul><li>Uses equally spaced , uniform strength sources distributed over a source plane or treatment volume. </li></ul><ul><li>Results in a nonuniform dose distribution, higher in the central region of treatment </li></ul><ul><li>Allowed higher source strength (1 mg/cm) compared to the Manchester System (0.66 & 0.33 mg/cm) </li></ul><ul><li>For planar implants, the QUIMBY TABLES give the mg-hr required to produce 1000R in the center of the treatment planes, up to 3cm distance from the plane of implant. </li></ul><ul><li>For PLANAR implants, the stated dose is thus the maximum dose in the plane of treatment. </li></ul><ul><li>For volume implants, the stated dose is the minimum dose within the implanted volume </li></ul><ul><li>Manchester data for QA in Quimby type implant geometries </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  28. 28. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA 1 cm spaced , UNIFORM STRENGTH [1 MgRa/cm] SOURCES CROSSING NEEDLES WHEN REQUIRED NONUNIFORM DOSE DISTRIBUTION CENTRE HIGH From TABLES – mg-h/1000R PLANAR – STATED DOSE – MAX DOSE VOLUME – STATED DOSE – MIN DOSE
  29. 29. C. THE MEMORIAL SYSTEM (Laughlin et al) <ul><li>Extension of Quimby system </li></ul><ul><li>Planning intra operative permanent volume implants of unresectable tumors </li></ul><ul><li>Characterized by computer generated dose distributions around lattices of point sources of uniform strength spaced 1cm apart. </li></ul><ul><li>Based on computer generated dose distributions, charts/Nomograms developed for different isotopes relating implant dimensions to the number of seeds, activity, and spacing that gave mg-hrs to deliver 1000 rads to a prescription point </li></ul><ul><li>These tables used proper exposure rate constant and include the effects of oblique filtration , elongation factor and tissue attenuation </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  30. 30. PARIS SYSTEM (Pierquin et al) <ul><li>Primarily for single & double plane implants </li></ul><ul><li>Especially removable/temporary implants of longer line sources, e.g 192 Ir wires. </li></ul><ul><li>GENERAL RULES </li></ul><ul><ul><li>Sources must be linear, parallel placed, uniformly spaced, equal length, source strength/linear activity. </li></ul></ul><ul><ul><li>The centres of all sources must be located in the same plane (central plane) </li></ul></ul><ul><ul><li>Spacing between sources should be wider when using long sources. </li></ul></ul><ul><ul><li>Dose specification based on an reference (stated) isodose -fixed at 85% of “ basal dose ” </li></ul></ul><ul><ul><li>BASAL DOSE - average of the minimum dose between sources inside implanted volume </li></ul></ul><ul><ul><li>If the guidelines are followed, then the reference isodose surface should encompass the whole target volume. </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  31. 31. Calculation of the basal dose rate [BD]: Planar (A, B) or curved surfaces (C). Basal doses calculated midway between each pair of sources and averaged. Calculation of the basal dose rate BD in triangles (A), in squares (B). Basal doses calculated equidistant from each of the adjacent sources.
  32. 32. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Paris System of dosimetry <ul><li>X = Minimum dose = basal dose </li></ul><ul><li>Average of basal doses = mean basal dose [elementary BD] </li></ul><ul><li>Reference dose = 0.85 basal dose (closely approximates minimum peripheral dose) </li></ul><ul><li>To consider an implant satisfactory, each basal dose rate should be within ±10% of the Mean basal dose rate </li></ul>X X X X X X X X X X X
  33. 33. UNACCEPTABLE IMPLANT SORRY!! THIS WAS MY FIRST IMPLANT, I’LL IMPROVE BEFORE YOUR TWO MORE SESSIONS ARE OVER! IMPLANTS WITH IMPERFECT GEOMETRY
  34. 34. ICRU RECOMMENDATIONS <ul><li>PTV , CTV similar to EBRT. No margin needed for PTV </li></ul><ul><li>Treatment volume is tissue volume encompassed by the reference isodose; ideally around CTV. </li></ul><ul><li>Reported doses defined in the central plane as in the Paris system, and renamed </li></ul><ul><ul><li>basal dose to Mean Central Dose (MCD) </li></ul></ul><ul><ul><li>Reference dose to Minimum Target dose (MTD) </li></ul></ul><ul><li>Two uniformity parameters </li></ul><ul><ul><li>Spread in the individual minimum doses averaged to get the mean </li></ul></ul><ul><ul><li>Ratio of the minimum target dose to the mean central dose. [MTD:MCD] </li></ul></ul>International Commission on Radiological Units. Dose and Volume Specification for Reporting Interstitial Therapy. Report No 58. Washington DC: ICRU Publications, 1997
  35. 35. COMPUTER SYSTEM <ul><li>Uniform strength sources, spaced uniformly (Eg: 1.0-1.5 cm, with larger spacing for larger size implants) and covering entire target volume. </li></ul><ul><li>Similar to Paris and Quimby; implant that is “ hotter “ in the middle than in periphery. </li></ul><ul><ul><li>This dose inhomogeneity accepted – more dose needed in centre to sterilize the tumor </li></ul></ul><ul><li>Safety margins for target volume - peripheral sources placed at target boundary with adequate coverage of tumor. </li></ul><ul><li>DOSE SPECIFIED by the isodose surface that just surrounds the target or implant. </li></ul><ul><li>NO CROSSING SOURCES - active length of the line sources should be suitably longer (=40% longer) than the length of the target volume </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  36. 36. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA RULES OF INTERSTITIAL IMPLANT SYSTEMS CHARACTERISTIC PATERSON-PARKER QUIMBY PARIS COMPUTER LINEAR STRENGTH VARIABLE (full intensity, 0.66 mgRa/cm; half intensity,0.33 mgRa/cm) CONSTANT (full intensity, 1mg Ra/cm; half intensity, 0.5 mgRa/cm) CONSTANT (0.6-1.8 mg Ra eq/ cm) CONSTANT (0.2-0.4 mg Ra eq/cm) SOURCE DISTRIBUTION PLANAR IMPLANTS (in periphery) Area <25cm 2 - 2/3 Ra Area 25-100cm 2 - 1/2 Ra Area >100cm 2 - 1/3 Ra UNIFORM UNIFORM UNIFORM VOLUME IMPLANTS CYLINDER: belt , four parts; core , two parts, each end one part SPHERE: shell , six parts; core , two parts CUBE: each side , one part; core , two parts UNIFORM distribution of sources throughout the volume Line sources arranged in parallel Line source arranged in parallel planes or cylindric volumes LINE SOURCE SPACING CONSTANT Approximately 1cm apart from each other or from crossing ends Same as Paterson-Parker CONSTANT [according to implant dimensions - larger spacing used in large volumes;8mm min to 15mm max separation CONSTANT 1-1.5cm, depending on size of implant (larger spacing for larger size implants) CROSSING NEEDLES Crossing needles required to enhance dose at implant ends Same as Paterson-Parker Crossing needles NOT used, active length 30%-40% longer than target length Crossing needles NOT used, active length of sources 30-40% larger than target length
  37. 37. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Plan Description/Documentation <ul><li>Interstitial </li></ul><ul><li>Permanent / Removable </li></ul><ul><li>Air-Kerma strengths </li></ul><ul><li>Source type / model </li></ul><ul><li>Type of template / applicator </li></ul><ul><li>Single / double / multiple plane </li></ul><ul><li>Optimization of source strength/position </li></ul><ul><li>Computer reference data (1-D. 2-D or 3-D) </li></ul><ul><li>Prescribed dose/dose rate/ treatment duration </li></ul><ul><li>Dose to critical points </li></ul><ul><li>Ensure compliance with all local & national regulations </li></ul>
  38. 38. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Sites Implanted by Brachytherapy <ul><li>Uncommon Sites: </li></ul><ul><ul><li>Eye – Uveal melanoma </li></ul></ul><ul><ul><li>Brain </li></ul></ul><ul><ul><li>Bladder </li></ul></ul><ul><ul><li>Urethra </li></ul></ul><ul><ul><li>Sarcomas </li></ul></ul><ul><ul><li>Endometrium </li></ul></ul><ul><ul><li>Penis </li></ul></ul><ul><ul><li>Vagina </li></ul></ul><ul><ul><li>Anorectal </li></ul></ul><ul><li>Common Sites </li></ul><ul><li>Prostate </li></ul><ul><li>Cervix </li></ul><ul><li>Head & Neck </li></ul><ul><li>Breast </li></ul><ul><li>Skin </li></ul>
  39. 39. INTERSTITIAL BRACHYTHERAPY IN HEAD AND NECK CANCERS <ul><li>CA TONGUE </li></ul><ul><li>CA FLOOR OF MOUTH </li></ul><ul><li>LIP </li></ul><ul><li>CHEEK/BUCCAL MUCOSA </li></ul><ul><li>NASAL VESTIBULE </li></ul><ul><li>OROPHARNX </li></ul><ul><li>SKIN CANCERS </li></ul><ul><li>SECONDARY NECK </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA RADICAL DOSE: 60-70Gy BOOST DOSE TO PRIMARY: 20-30Gy; 2-3 wks after completion of EBRT
  40. 40. CANCER OF TONGUE <ul><li>Those on lateral border of the anterior two-third of the tongue. </li></ul><ul><li><3cm diameter </li></ul><ul><li>Well differentiated </li></ul><ul><ul><li>Radical ISBT 60-70Gy </li></ul></ul><ul><li>If larger/ poorly differentiated </li></ul><ul><ul><li>BOOST primary with 20-30Gy; 2-3 wks after completion of EBRT </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  41. 41. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Interstitial implants - tongue implant tongue tongue Catheter loop Button
  42. 42. CA OROPHARYNX <ul><li>SCCs of base of tongue, the soft palate, the tonsillar fossa, and the vallecula less than 50 mm in diameter </li></ul><ul><li>CONTRAINDICATION </li></ul><ul><ul><li>Primary extends to retromolar trigone, nasopharynx, larynx, hypopharynx, or invades bone. </li></ul></ul><ul><ul><li>Associated with bulky cervical lymph nodes. </li></ul></ul><ul><li># <6Gy between 6hours or more </li></ul>
  43. 43. CANCER OF FLOOR OF MOUTH <ul><li>Indications – similar to tongue lesions </li></ul><ul><li>If bone fixation – risk of osteoradionecrosis </li></ul><ul><li>Risk of necrosis higher than for tongue. </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  44. 44. Cancer of Lip <ul><li>Esp >1/3 rd of lip </li></ul><ul><ul><li>Sx not practical -Extensive plastic surgery </li></ul></ul><ul><li>Post RT recurrence salvage </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  45. 45. CANCER OF CHEEK/BUCCAL MUCOSA <ul><li>Single plane implant </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  46. 46. SKIN CANCER <ul><li>epidermal skin cancers T1 - T2 N0 on the face </li></ul><ul><li>Post EBRT Boost in larger tumourS </li></ul><ul><li>Similar cure rate – but needs hospital admission </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Hypodermic needles for Skin ISBT
  47. 47. Ca PENIS <ul><li>Radical dose – 56-60 Gy </li></ul><ul><li>CONTRAINDICATION </li></ul><ul><ul><li>Infiltration of corpora cavernosa </li></ul></ul><ul><ul><li>Greater than 4cm in any dimension </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Pierquin-Chassagne applicator
  48. 48. BREAST CANCER <ul><li>INDICATION </li></ul><ul><ul><li>In BCT-Post lumpectomy site boost after EBRT </li></ul></ul><ul><ul><li>boost to the tumor residue after EBRT for inoperable disease </li></ul></ul><ul><ul><li>salvage therapy for local recurence </li></ul></ul><ul><ul><li>sole method of radiation following lumpectomy </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Further reading & Guidelines : Oncology, Vol. 15, No. 2 (February 2001).
  49. 49. DOSE FOR BREAST INTERSTITIAL BRACHYTHERAPY <ul><li>POST EBRT+ POST Complete Resection </li></ul><ul><ul><li>Dose of 15 Gy </li></ul></ul><ul><li>After incomplete resection </li></ul><ul><ul><li>20-25 Gy </li></ul></ul><ul><li>HDR - 10Gy in 1 fraction or doses up to 20 Gy in 4 to 6 Gy fractions. </li></ul>
  50. 50. INTERSITIAL BRACHYTHERAPY IN PELVIS <ul><li>COMMON SITES </li></ul><ul><ul><li>Cervix </li></ul></ul><ul><ul><li>Anal canal </li></ul></ul><ul><ul><li>Prostate </li></ul></ul><ul><ul><li>Vagina </li></ul></ul><ul><li>RARE SITES </li></ul><ul><ul><li>Urinary bladder </li></ul></ul><ul><ul><li>Vulva </li></ul></ul><ul><ul><li>Urethra </li></ul></ul><ul><ul><li>Endometrium </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  51. 51. Indications of interstitial implantation in carcinoma cervix <ul><li>Extensive residual disease(not likely to be taken care of by intracavitary application) </li></ul><ul><li>Os not negotiable </li></ul><ul><li>Extensive parametrial involvement </li></ul><ul><li>Recurrent disease(post RT/post surgery) </li></ul><ul><li>Narrow vagina </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Further reading on practice guidelines - International Journal of Radiation Oncology Biology Physics , Vol. 48, No.1, pp 201-211, 2000, and Vol. 52, No. 1, pp 33-48, 2002.
  52. 52. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA MUPIT ( Martinez Universal Perineal Interstitial Template) GUIDE HOLES
  53. 53. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Syed Neblett template
  54. 54. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  55. 55. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  56. 56. CANCER OF VAGINA <ul><li>Limited superficial lesions </li></ul><ul><ul><li>radical implant </li></ul></ul><ul><li>Advanced stages </li></ul><ul><ul><li>EBRT f/b boost to primary using implant </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  57. 57. CA ENDOMETRIUM <ul><li>NOT COMMONLY DONE </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA the International Journal of Radiation Oncology Biology Physics, Vol. 48, No. 3, pp 779-790, 2000.
  58. 58. Anorectal Cancers <ul><li>Indication </li></ul><ul><ul><li>Post EBRT local boost. </li></ul></ul><ul><ul><li>Disease recurrence post radiotherapy </li></ul></ul><ul><ul><li>Palliative role (If elderly advanced and APR not feasible for medical reasons 40 Gy EBRT F/B IMPLANT) </li></ul></ul><ul><li>Not to implant > 60-70% of the circumference of the anal canal </li></ul><ul><li>AFTER 30-40 Gy, tumor implanted in 6-8 wks. Boost dose to primary is 20-30Gy. </li></ul><ul><ul><li>Results comparable to radical surgery </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  59. 59. TUMOURS OF THE URETHRA <ul><li>Rarely performed </li></ul><ul><li>INDICATIONS </li></ul><ul><ul><li>Primary tumors of urethra </li></ul></ul><ul><ul><li>Boost after EBRT </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  60. 60. Bladder cancer <ul><li>Not done now </li></ul><ul><li>After cystotomy, Superficial part resected and plastic tubes inserted into base </li></ul><ul><li>2000-3000cGy + EBRT to pelvis at dose of 45-50Gy </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  61. 61. Indications for brachytherapy in carcinoma prostate <ul><li>Early stage disease as a sole modality </li></ul><ul><li>As boost after external beam radiotherapy </li></ul><ul><li>In cases of recurrent disease </li></ul><ul><ul><li>BOTH PERMANENT & TEMPORARY IMPLANTS </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  62. 62. Indication for prostate brachytherapy monotherapy DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA IPSS: International Prostate Symptom Score. Q max ml/s: urinary flow rate. Ash D, Flynn A, Battermann J. ESTRO/EAU Urological Brachytherapy Group; EORTC Radiotherapy Group. ESTRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer. Radiother Oncol 2000;57:315 — 21. Recommended Do well Optional Fair PSA (ng/ml) <10 10 — 20 Gleason score 5 — 6 7 Stage T1c — T2a T2b — T2c IPSS 0 — 8 9 — 19 Prostate volume (g) <40 40 — 60 Q max ml/s >15 10-15
  63. 63. CONTRA-INDICATIONS TO PERMANENT SEED IMPLANTS <ul><li>Life expectancy less than 5 years. </li></ul><ul><li>The presence of metastatic disease. </li></ul><ul><li>Recent TURP with persisting large prostatic defect. </li></ul><ul><li>Bleeding disorders; patients on regular Aspirin/or anticoagulants should stop it at least seven days before implantation. </li></ul><ul><li>Prostate gland of greater than 50 ccs </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Further reading :International Journal of Radiation Oncology Biology Physics, Vol. 1, No. 5, pp 1422-1430, 2001.
  64. 64. BRACHYTHERAPY DOSE CA PROSTATE <ul><li>125 Iodine - 145 Gy </li></ul><ul><ul><li>Post EBRT boost - 95 to 100 Gy. </li></ul></ul><ul><li>103 Paladium </li></ul><ul><ul><li>115 Gy [brachytherapy alone] </li></ul></ul><ul><ul><li>Post EBRT Boost-90 Gy </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA American brachytherapy society (ABS) recommendations for transperineal permanent brachytherapy of prostate cancer
  65. 65. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  66. 66. Episcleral plaque Brachytherapy of uveal melanomas. <ul><li>INDICATION </li></ul><ul><ul><li>Non-metastatic Medium-sized choroidal melanoma (between 2.5 and 10 mm in height and <16 mm basal diameter) </li></ul></ul><ul><li>Dose[ABS] </li></ul><ul><ul><li>125 I dose of 85 Gy at a dose rate of 0.60-1.05 Gy/h </li></ul></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA Nag S, Quivey JM, Earle JD, Followill D, Fontanesi J, Finger PT; American Brachytherapy Society. The American Brachytherapy Society recommendations for brachytherapy of uveal melanomas. Int J Radiat Oncol Biol Phys. 2003 Jun 1;56(2):544-55.
  67. 67. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA INTERSTITIAL BRACHYTHERAPY SITES LIVER METASTASIS / PERMANENT
  68. 68. BRAIN TUMORS <ul><li>indicated in recurrent tumors </li></ul><ul><li>50 - 60 Gy </li></ul>DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA
  69. 69. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA <ul><li>used alone or in combination with EBRT </li></ul><ul><li>Brachy alone 65-70Gy </li></ul><ul><li>ABS Recommendation for intraoperative HDR brachytherapy </li></ul><ul><ul><li>Doses 10-15 Gy (prescribed at a 0.5 cm depth of this brachytherapy is used as a boost to EBRT </li></ul></ul>SOFT TISSUE SARCOMA Further Reading -International Journal of Radiation Oncology Biology Physics, Vol. 49, No. 4, pp 1033-1043, 2001.
  70. 70. DEPARTMENT OF RADIATION ONCOLOGY, REGIONAL CANCER CENTRE, PGIMS, ROHTAK, HARYANA THANK YOU ALL

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