MOULD BRACHYTHERAPY

1. 3D IMAGING
and
MOULD BRACHYTHERAPY
DR KANHU CHARAN PATRO

2. General
principles-
mould brachy

4. Basic principles
• Best fit on regular surface
• Irregular surface needs customization
• Source to treatment depth best if 5mm
• Beyond 5 mm ,there will be overdose
• Keep the 150/200 isodose on mould
• 100% isodose on skin
• Follow DNR ratio

6. Applications
• Oral cavity
– Lip
– Buccal
– Alveolar
– Tongue
– Palate
• Skin
– BCC
– SqCC
– Merckel
• Sarcoma superficial
• Penis
• Many more

8. (A) Bucco masseteric region bounded by zygomaticus major (arrowhead), masseter(m), buccinator (+)
inserting into pterygomandibular raphe (*) and terminal parotid duct(arrow).
(B) Shows orbicularis oris (arrowhead) and levator anguli oris (arrow)

9. Puffed check
coronal
• Showing oral cavity
proper with tongue
(asterisk),
• Vestibule (short arrow),
• Lower gingivobuccal
sulcus (long arrow),
• Hard palate(^)
• Buccal mucosa closely
apposed to buccinator
(+)

10. Lower GBS involvement

11. A) Axial CECT showing the Puffed Cheek technique in
B) That separates the buccal and gingival surfaces with air depicting that epicenter of lesion
(arrows) is in the buccal mucosa .The lesion does not abut mandible as appears in A

12. Soft palate- soft tissue window

13. Hard palate- bone window

14. Case-1

21. Reaction
Usually no reaction during discharge
Look at fortnight after discharge
If good reaction
Means
brachy has shown its action
Do not worry
No need to be sorry
Saline wash with steroid ointment
That is my commitment
It will heal
That is my deal

24. How to prevent bad reaction?
• Follow DNR
• Dose non uniformity ratio

25. TARGET DOSE EVALUATION

26. TARGET DOSE EVALUATION

27. DNR- Dose Non-uniformity ratio
DNR-V150/V100

29. THANK YOU SIR

30. Case-2

33. Sandwich
molud

35. 8/13/2022 5:51:19 PM 35
Case-3

36. 8/13/2022 5:51:19 PM 36

37. Applicator in situ with IOP

38. Complete response –towards healing
hypo-pigmentation

39. 2 months follow up

40. TO HOLD THE MOULD
PLEASE MAKE THERMOPLASTIC MOULD

41. Make a mask

42. 8/13/2022
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
42
Case-5

43. Case-4

44. Finger

47. Hard palate

48. Scalp

49. Tongue

51. Penis

53. HISTORY
• Painful swallowing
• Mass in the upper part of palate

54. DIAGNOSIS BY LOCAL ENT SURGEON
• 1.5 x 1.5 cm uvular growth
• Not extending to soft palate
• Planned biopsy

55. EXICISIONAL BIOPSY
• Outside by ENT surgeon

56. BIOPSY REPORT
• PT-1X0.8X0.8 CM
• Squmaous cell carcinoma
• Moderately differentiated
• Margins not commented

57. NECK NODE EVALUATION
• NON SPECIFIC LYMPHADENOPATHY
– MRI
– USG
– CT

58. FINAL DIAGNOSIS
• CANCER UVULA –POST EXICIONAL BIOPSY
• MARGIN NOT COMENTED
• pT1NOMO

59. TUMOR BOARD PLAN
• BRACHYTHERAPY
• MOULD
• EQD2- 60Gy

60. REQUIREMENTS
FOR MOULD PREPARATION
• ALGINATE IMPRESSION MATERIAL
• Cast
• Dental stone
• Water
• U-CLASP
• COLD CURE ACRYLIC powder and
liquid
• 2ml syringe
• Spatula
FOR BRACHY
• Gention violet
• Ear bud
• 2ml syringe
• Spatula
• Miro pore
• Copper wire
• Quickfix
• Xylocaine spray

61. MOULD PREPARATION

62. SELECTION OF IMPRESSION TRAY

63. MIXING ALGINATE IMPRESSION MATERIAL

64. UPPER IMPRESSION TAKEN WITH
ALGINATE IMPRESSION MATERIAL

65. MIXING DENTAL STONE WITH WATER

66. POURING OF CAST WITH DENTAL STONE

67. DENTAL CAST

68. PREPARATION OF U-CLASP WITH SS WIRE

69. PREPARATION OF U-CLASP WITH SS WIRE

70. POURING OF CAST WITH DENTAL STONE

71. U-CLASP

72. DENTAL CAST WITH FOUR U-CLASPS

73. APPLICATION OF SEPARATING MEDIUM

74. DENTAL CAST, COLD CURE ACRYLIC POWDER AND LIQUID

75. SPRINKLE TECHNIQUE

76. SPRINKLE TECHNIQUE

77. SPRINKLE TECHNIQUE

78. REMOVAL OF PROSTHESIS FROM DENTAL CAST

79. AFTER TRIMMING OF SHARP MARGINS

80. CHECKING THE FIT OF PROSTHESIS IN PATIENTS MOUTH

81. ADDITION OF MODELLING WAX TO PROSTHESIS

82. IOP in patients mouth

83. IOP IN PATIENTS MOUTH

84. Intra oral Prosthesis
INTRA ORAL PROSTHESIS

85. SPACING OF WIRES

86. GROOVING

87. FIXING WITH QUICK FIX

88. GENTION VIOLET

89. EAR BUD

90. EAR BUD –CUT ONE SIDE

91. 2ML SYRINGE

92. FILL THE EAR BUD

93. MARK THE TARGET AREA

94. TAKING IMPRESSION AND
EXTRAPOLATION ON MOULD

95. COPPER WIRE

96. FXING THE COPPER WIRE

97. FINAL MOULD

98. CONTACTING WITH PPW

99. SEPARATING THE PPW BY RYLE’S TUBE

100. PLANNING CT
• 1 MM SLICE
• SUPINE
• WITH MOULD
• WITH IOP
• VERTEX TO CLAVICLE
• MULTIPLANNAR

101. CATHETER NUMBERING

102. CATHETER RECONSTRUCTION

103. TARGET DELINEATION
• Target definition of the Gross Tumor Volume (GTV)
and Clinical Target Volume (CTV) are usually
performed by clinical examination aided by imaging
and intraoperative findings.
• In brachytherapy, typically no additional margin is
required to ensure that theCTV receives the planned
dose and therefore.
• Unlike external beam irradiation, CTV and PTV
(Planning Target Volume) are considered equivalent

104. DOSE SELECTION

105. DOSE SELECTION
• 4GY
• TWICE DAILY
• 13/14 FRACTIONS
• ALPHA/BETA-10

106. TREATMENT GAP

107. PLANNING
• ACCURATELY MEASURED CATHTER LENGTH BEFORE CT
• CATHTER NUMBERING AND MARKED
• CATHTER RECONSTRUCTION
• PLANNED BY IPSA
• OPTIMIZED GRAPHICALLY
• TREATMENT CALCULATION
• VERIFICATION
• EXECUTION

108. TARGET DOSE EVALUATION
• CTV coverage is adequate (i.e., D90 is at least 90% of
the prescribed dose)
• The prescription dose is usually the minimum dose
received by the CTV or a CTV surrogate (i.e., the D90 >
100, V100 > 90%)
• Dose non-uniformity ratio (DNR= V100/V150)
• DNR should be equal or lower than 0.36
• The optimal spacing between applicators is <15 mm

109. TARGET DOSE EVALUATION
COVERAGE INDEX
 CTV VOLUME 0.32CC DESIRABLE
 DNR INDEX V150 / V100 = 34.04/96.42 =0.35 0.36 T0 0.5
 D90
98.34% >90%-100%
 V100
96.42% >90%
 V150
34.04% ALARA
 V200
8.94% ALARA
 V300
2.67% ALARA

110. ISODOSE IN ALL PLANES
BLUE 85%
RED 100%
ORANGE 150%
WHITE 200%
GREEN 300%

111. DVH STATISTICS

112. DRR

113. OAR EVALUATION

114. SEPARATING THE BOT

115. SEPARATING THE BOT

116. SEPARATING THE BOT

117. XYLOCAINE SPRAY

118. IOP- SPACER

119. TREATMENT POSITIONING

120. INTRATREATMRNT CARE
• ORAL HYGIENE
• SOS ANALGESICS

121. POST TREATMENT CARE
• ORAL HYGIENE
• SOS ANALGESICS
• COUNSEL ABOUT THE UPCOMING REACTIONS

122. FOLLOW UP
1. FOLLOW UP AFTER 3 MONTHS
2. LOCAL EXAMINATION
3. USG NECK FOR NODES

123. UVULA
• NOT REPORTED YET

124. SUMMARY
• Follow GEC-ESTRO guidelines
• Train the brain of your dentist
• Follow steps
• Wires/source should not touch necked to any surface
• Use lead /IOP
• Reactions usually observed after treatment- do not
get panic , wait
• Counsel

126. MY REGARDS

127. SMART THINKING
8/13/2022 5:51:20 PM 127

128. 8/13/2022 5:51:20 PM 128

132. we
• Radiation oncologist
We are the best plastic surgeons

133. 10/20/12 01:12 PM 133

134. 10/20/12 01:12 PM 134

135. NO AMPUTATION PLEASE
8/13/2022 5:51:20 PM 135

137. 137
?