Permanent prostate seed implant brachytherapy: report of the American Association of Physicists in Medicine Task Group No. 64

Benefits of a dual sagittal crystal transducer for ultrasound imaging during I-125 seed implantation for permanent prostate brachytherapy

Purpose

To investigate whether a longer sagittal view and less movement using a dual sagittal crystal probe (DSCP) for trans rectal ultra sound (TRUS) allow for more accurate online-planning in I-125 permanent implant brachytherapy of the prostate, compared to a single sagittal crystal probe (SSCP).

Material and methods

Between March 2008 and March 2010, 50 patients with prostate cancer were consecutively included in the study. The first 25 of these patients had both their pre- and online-planning based on a single sagittal crystal probe (SSCP). The treatment-plans of the other 25 patients were based on a DSCP TRUS. Three weeks after implantation a post-planning was made based on CT. TRUS online and CT post-plan dose-volume histogram (DVH) parameters, D₉₀ and V₁₀₀, were compared for both groups. Also, the post-plan DVH parameters of SSCP were compared to DSCP. The possible factors that might influence the post-plan D₉₀ and V₁₀₀ were analysed using Analysis of Variance (ANOVA).

Results

SSCP and DSCP online mean D₉₀ and V₁₀₀ were significantly larger than post-plan mean D₉₀ and V₁₀₀ (P < 0.01). The post-plan mean D₉₀ and mean V₁₀₀ were both non-significantly larger for SSCP based post-plans compared to DSCP based post plans (P = 0.76 and P = 0.68). ANOVA showed significant impact of prostate volume on the post-plan D₉₀ and V₁₀₀.

Conclusions

The advantages of the dual sagittal crystal probe did not lead to more accurate online planning by investigating DVH-parameters. The only factor found to have influence on the DVH-parameters was the prostate volume.

Investigating the dosimetric and tumor control consequences of prostate seed loss and migration

PURPOSE

Low dose-rate brachytherapy is commonly used to treat prostate cancer. However, once implanted, the seeds are vulnerable to loss and movement. The goal of this work is to investigate the dosimetric and radiobiological effects of the types of seed loss and migration commonly seen in prostate brachytherapy.

METHODS

Five patients were used in this study. For each patient three treatment plans were created using Iodine-125, Palladium-103, and Cesium-131 seeds. The three seeds that were closest to the urethra were identified and modeled as the seeds lost through the urethra. The three seeds closest to the exterior of prostatic capsule were identified and modeled as those lost from the prostate periphery. The seed locations and organ contours were exported from Prowess and used by in-house software to perform the dosimetric and radiobiological evaluation. Seed loss was simulated by simultaneously removing 1, 2, or 3 seeds near the urethra 0, 2, or 4 days after the implant or removing seeds near the exterior of the prostate 14, 21, or 28 days after the implant.

RESULTS

Loss of one, two or three seeds through the urethra results in a D(90) reduction of 2%, 5%, and 7% loss, respectively. Due to delayed loss of peripheral seeds, the dosimetric effects are less severe than for loss through the urethra. However, while the dose reduction is modest for multiple lost seeds, the reduction in tumor control probability was minimal.

CONCLUSIONS

The goal of this work was to investigate the dosimetric and radiobiological effects of the types of seed loss and migration commonly seen in prostate brachytherapy. The results presented show that loss of multiple seeds can cause a substantial reduction of D(90) coverage. However, for the patients in this study the dose reduction was not seen to reduce tumor control probability.

Quality indicators and technique for analyzing permanent I-125 prostate seed implants: seven years postimplant dosimetry evaluation

PURPOSE

The roles of postimplant dosimetry (PID) after permanent I-125 implant are to identify and rectify inadequate implants, assess the dosimetric quality indicators, and evaluate dose to the organs at risk. The aim of the current work was to assess the progress of prostate implant quality via postimplant dosimetry over seven years.

METHODS

The following factors were investigated to assess the PID results obtained over seven years: the improvement in implant technique, the computed tomography (CT) delineation-based PID versus ultrasound-CT (US-CT) fusion-based PID, and the evolution of parameters such as D90 and NDR (natural dose ratio). The correlation between dosimetric parameters and clinical outcomes were also evaluated.

RESULTS

The seven years PID learning curve shows clear changes in dosimetric trend for the 265 patients studied. Manual target contouring on CT was shown to overestimate the prostate volume when compared to ultrasound data, translating to CT-based D90 values being lower than US-CT D90. It was found that NDR does not contribute with additional dosimetric information to postimplant dosimetry evaluation. Patient follow-up data show that 4.7% patients have relapsed, and urinary retention was reported in 2.7% of the patients.

CONCLUSIONS

CT-based PID was found less reliable than US-CT fusion-based PID due to target volume overestimation. This result shows the biased interpretation of low D90 values based on CT-based targeting, providing unreliable correlations between D90 and relapse probability. The low urinary retention statistics are in accordance with the PID data for the organ, as only 5.2% of patients had their PID D10 > 218 Gy, i.e., above the recommended GEC-ESTRO guidelines. Besides the "learning" component, the PID D90 curve is influenced by the PID technique.

125I seed irradiation induces up-regulation of the genes associated with apoptosis and cell cycle arrest and inhibits growth of gastric cancer xenografts

Background

Iodine 125 (125I) seed irradiation can be used as an important supplementary treatment for unresectable advanced gastric cancer. Here, we aim to comprehensively elucidate the biological effects induced by 125I seed irradiation in human gastric cancer xenograft model by using global expression and DNA methylation analyses.

Methods

The 48 mice bearing NCI-N87 gastric cancer xenografts were randomly separated into 2 groups: sham seeds (O mCi) were implanted into the control group (n = 24); 125 l seeds (0.9 mCi) were implanted into the treatment group (n = 24). The mitotic index and apoptotic index were evaluated by quantitative morphometric analysis of the expression of proliferating cell nuclear antigen (PCNA) and in situ terminal transferase-mediated fluorescein deoxy- UTP nick end labeling (TUNEL), respectively. Global gene expression changes induced by 125I seed irradiation were analyzed by using Nimblegen Human gene expression array. DNA methylation profile in the tumors from control group was investigated with methylated DNA immunoprecipitation (MeDIP) and Nimblegen CpG promoter microarrays. The changes in the methylation status of selected genes were further investigated by using MeDIP-PCR.

Results

125I seed irradiation suppresses the growth of gastric cancer xenografts in nude mice. PCNA staining and tissue TUNEL assays showed that both inhibition of cell proliferation and induction of apoptosis contribute to the 125I-induced tumor suppression in nude mouse model. Gene expression profiles revealed that the expression levels of several hundred genes, many of which are associated with apoptosis or cell cycle arrest, including BMF, MAPK8, BNIP3, RFWD3, CDKN2B and WNT9A, were upregulated following 125I seed irradiation. Furthermore, the up-regulation of some of these genes, such as BNIP3 and WNT9A, was found to be associated with irradiation-induced DNA demethylation.

Conclusions

This study revealed that 125I seed irradiation could significantly induce the up-regulation of apoptosis- and cell cycle-related genes in human gastric cancer xenografts. And some of the up-regulation might be attributed to 125I-irradiation induced demethylation in gene promoter regions. Collectively, these findings provided evidence for the efficacy of this modality for the treatment of gastric cancer.

A Device for the Automated Loading and Detection of Brachytherapy Elements Using Nonmechanical Methods for use in Prostate Cancer Treatment

Within the recent resurgence of brachytherapy as treatment for prostate cancer, many new devices have been conceived in the preparation of surgical brachytherapy equipment. Specifically, this work encompasses the automated preparation of preloaded surgical brachytherapy applicators or “needles” through the loading of radioactive seed elements and benign spacer elements. While traditionally a manual operation, current device methodology in this application revolves around semi-automatic mechanical interaction within the element loading procedure. Mechanical interaction can subject elements to damage, specifically seed elements due to thin metallic construct. Damage to elements within a loading system can result in failure of the performed brachytherapy treatment causing potential harm to the patient. Hesitancy in acceptance of these mechanical separation element loading devices can be attributed to the failure nature of these devices. This work seeks to solve the current issue of element damage through noninteraction while offering improvement through full automation of the loading procedure.

Calculating prescription doses for new sources by biologically effective dose matching

PURPOSE

In current clinical practice, single isotopes, such as (125)I or (103)Pd, are used as single sources in prostate seed implants. A mixture of two radionuclides in the seeds has been proposed for prostate cancer treatment. This study investigates a method for determining the prescription dose for these new seeds using the biological effective dose (BED).

METHODS

Ten prostate cancer cases previously treated using single radionuclide seeds were selected for this study. The BED distribution for these cases was calculated. Plans using other radionuclides were then calculated based on this BED distribution. Prescription values could then be obtained for the calculated plans. The method was verified by calculating the prescription dose for (103)Pd and (125)I and comparing to clinical values. The method was then applied to a hybrid seed that consisted of a mixture of (125)I and (103)Pd radionuclides, which deliver equal dose to 1cm from the source in water (50/50D@1 cm). A prescription BED value was also calculated.

RESULTS

A prescription BED of 110 Gy was found to correlate to a prescription dose of 145, 120, and 137 Gy for (125)I, (103)Pd, and 50/50D@1 cm hybrid seeds, respectively.

CONCLUSION

The method introduced in this article allows one to calculate the prescription dose for new and novel sources in brachytherapy. The method was verified by calculating a prescription dose for (125)I and (103)Pd radionuclides that coincides with values used clinically.

Evaluation of the effect of prostate volume change on tumor control probability in LDR brachytherapy

Purpose

This study evaluates low dose-rate brachytherapy (LDR) prostate plans to determine the biological effect of dose degradation due to prostate volume changes.

Material and methods

In this study, 39 patients were evaluated. Pre-implant prostate volume was determined using ultrasound. These images were used with the treatment planning system (Nucletron Spot Pro 3.1^®) to create treatment plans using ¹⁰³Pd seeds. Following the implant, patients were imaged using CT for post-implant dosimetry. From the pre and post-implant DVHs, the biologically equivalent dose and the tumor control probability (TCP) were determined using the biologically effective uniform dose. The model used RBE = 1.75 and α/β = 2 Gy.

Results

The prostate volume changed between pre and post implant image sets ranged from –8% to 110%. TCP and the mean dose were reduced up to 21% and 56%, respectively. TCP is observed to decrease as the mean dose decreases to the prostate. The post-implant tumor dose was generally observed to decrease, compared to the planned dose. A critical uniform dose of 130 Gy was established. Below this dose, TCP begins to fall-off. It was also determined that patients with a small prostates were more likely to suffer TCP decrease.

Conclusions

The biological effect of post operative prostate growth due to operative trauma in LDR was evaluated using the concept. The post-implant dose was lower than the planned dose due to an increase of prostate volume post-implant. A critical uniform dose of 130 Gy was determined, below which TCP begun to decline.

Rectal toxicity and rectal dosimetry in low-dose-rate (125)I permanent prostate implants: a long-term study in 1006 patients

OBJECTIVE

To describe the acute and late rectal toxicity in 1006 prostate brachytherapy patients implanted 1998-2003. To determine whether rectal dose-volume histogram as well as patient and treatment factors were associated with rectal toxicity.

METHODS AND MATERIALS

Median followup was 60.7 months. Rectal dosimetry was calculated as dose-volume histogram of the rectum using Day 28 CT-based dosimetry and expressed as volume of the rectum in cc receiving 50%, 100%, and 150% of the prescription dose (VR(50cc), VR(100cc), and VR(150cc), respectively). Univariate and multivariate analyses were performed to examine the influence of patient, implant, dosimetry, and learning curve factors on the development of acute and late toxicities using a modified Radiation Therapy Oncology Group (RTOG) scale. Acute toxicity was analyzed using logistic regression and late toxicity using Cox proportional hazards regression. Analysis of variance was used to examine the association between rectal toxicity and rectal dose.

RESULTS

Rectal dosimetry in 93.5% and rectal toxicity in 96.2% have been recorded. Median VR(100)=1.05cc. Late RTOG Grades 0, 1, 2, 3, and 4 were recorded in 68%, 23%, 7.3%, 0.9%, and 0.2% patients, respectively. On multivariate analysis, acute RTOG ≥2 rectal toxicity was associated with urinary retention (p=0.036) and learning curve (p=0.015); late RTOG ≥2 was associated with the presence of acute toxicity (p=0.0074), higher VR(100) (p=0.030) and learning curve (p=0.027).

CONCLUSIONS

Late rectal RTOG ≥2 rectal toxicity in this cohort was 8%. Increased VR(100), presence of acute rectal toxicity, and learning curve were associated with higher rate of late RTOG ≥2 toxicity. Severe late rectal toxicity after prostate brachytherapy was rare.

Experimental measurements and Monte Carlo simulations of dose perturbation around a nonradioactive brachytherapy seed due to 6- and 18-MV photons

PURPOSE

Radioactive seeds used in permanent prostate brachytherapy are composed of high-Z metals and may exceed 100 in a patient. If supplemental external beam treatment is administered afterward, the seeds may cause substantial dose perturbation, which is being investigated in this article.

METHODS AND MATERIALS

Film measurements using 6-MV beam were primarily carried out using Kodak XV2 film layered above and below a nonradioactive iodine-125 ((125)I) seed. Monte Carlo simulations were carried out using DOSXYZnrc. Other experimental comparisons looked at changing beam energy, depth, and field size, including two opposing fields' pair. Effect of multiple seeds spatially spaced 0.5cm vertically was also studied.

RESULTS

For a single (125)I seed, on XV film, there is a localized dose enhancement of 6.3% upstream and -10.9% downstream. With two opposing fields, a cold spot around the seed of ∼3% was noticed. Increasing beam energy and field size decreased the magnitude of this effect, whereas the effect was found to increase with the increasing Z of material. DOSXYZnrc and EBT-2 film verified maximum dose enhancement of +15% upstream and -20% downstream of the (125)I seed surface.

CONCLUSIONS

In general, the dose perturbation because of the seeds was spatially limited to ∼2mm upstream and ∼5mm downstream to the incident beam. Similar to other heterogeneities, the seeds perturbation depends on incident beam energy, field size, and its Z. With multiple seeds spatially apart and multiple radiation fields routinely used in external beam radiotherapy, the cumulative effect may not result in clinically significant dose perturbation.

Radiobiologically based treatment plan evaluation for prostate seed implants

Purpose

Accurate prostate low dose-rate brachytherapy treatment plan evaluation is important for future care decisions. Presently, an evaluation is based on dosimetric quantifiers for the tumor and organs at risk. However, these do not account for effects of varying dose-rate, tumor repopulation and other biological effects. In this work, incorporation of the biological response is used to obtain more clinically relevant treatment plan evaluation.

Material and methods

Eleven patients were evaluated. Each patient received a 145 Gy implant. Iodine-125 seeds were used and the treatment plans were created on the Prowess system. Based on CT images the post-implant plan was created. In the post-plan, the tumor, urethra, bladder and rectum were contoured. The biologically effective dose was used to determine the tumor control probability and the normal tissue complication probabilities for the urethra, bladder, rectum and surrounding tissue.

Results

The average tumor control probability and complication probabilities for the urethra, bladder, rectum and surrounding tissue were 99%, 29%, 0%, 12% and 6%, respectively. These measures provide a simpler means for evaluation and since they include radiobiological factors, they provide more reliable estimation of the treatment outcome. 

Conclusions

The goal of this work was to create more clinically relevant prostate seed-implant evaluation by incorporating radiobiological measures. This resulted in a simpler descriptor of treatment plan quality and was consistent with patient outcomes.

Reconstruction of brachytherapy seed positions and orientations from cone-beam CT x-ray projections via a novel iterative forward projection matching method

PURPOSE

To generalize and experimentally validate a novel algorithm for reconstructing the 3D pose (position and orientation) of implanted brachytherapy seeds from a set of a few measured 2D cone-beam CT (CBCT) x-ray projections.

METHODS

The iterative forward projection matching (IFPM) algorithm was generalized to reconstruct the 3D pose, as well as the centroid, of brachytherapy seeds from three to ten measured 2D projections. The gIFPM algorithm finds the set of seed poses that minimizes the sum-of-squared-difference of the pixel-by-pixel intensities between computed and measured autosegmented radiographic projections of the implant. Numerical simulations of clinically realistic brachytherapy seed configurations were performed to demonstrate the proof of principle. An in-house machined brachytherapy phantom, which supports precise specification of seed position and orientation at known values for simulated implant geometries, was used to experimentally validate this algorithm. The phantom was scanned on an ACUITY CBCT digital simulator over a full 660 sinogram projections. Three to ten x-ray images were selected from the full set of CBCT sinogram projections and postprocessed to create binary seed-only images.

RESULTS

In the numerical simulations, seed reconstruction position and orientation errors were approximately 0.6 mm and 5 degrees, respectively. The physical phantom measurements demonstrated an absolute positional accuracy of (0.78 +/- 0.57) mm or less. The theta and phi angle errors were found to be (5.7 +/- 4.9) degrees and (6.0 +/- 4.1) degrees, respectively, or less when using three projections; with six projections, results were slightly better. The mean registration error was better than 1 mm/6 degrees compared to the measured seed projections. Each test trial converged in 10-20 iterations with computation time of 12-18 min/iteration on a 1 GHz processor.

CONCLUSIONS

This work describes a novel, accurate, and completely automatic method for reconstructing seed orientations, as well as centroids, from a small number of radiographic projections, in support of intraoperative planning and adaptive replanning. Unlike standard back-projection methods, gIFPM avoids the need to match corresponding seed images on the projections. This algorithm also successfully reconstructs overlapping clustered and highly migrated seeds in the implant. The accuracy of better than 1 mm and 6 degrees demonstrates that gIFPM has the potential to support 2D Task Group 43 calculations in clinical practice.

Radioactive seed migration after prostate brachytherapy with iodine-125 using loose seeds versus stranded seeds

OBJECTIVES

To assess the incidence and clinical parameters that could influence migration of seeds in localized prostate cancer patients treated by stranded versus loose sources by Iodine-125 brachytherapy.

MATERIALS AND METHODS

100 patients were treated from January/1998 until December/2006. Age, PSA, clinical stage, Gleason, prostate volume, number of seeds, activity of radioactive seeds, and dosimetric parameters, such as V100, V150 and D90 were evaluated.

RESULTS

Mean follow-up was 79 months (18 - 120. CI 95%: 72 - 85). Overall, 6 of 100 patients experienced seed migration. Seed migration was found in 4/50 (8%) patients using loose seeds and in 2/50 (4%) treated by stranded seeds. Mean value dosimetric parameters for stranded seeds were greater than those for loose seeds (V100(%): 88.7/82, D90(Gy): 149.2/140.3, D90(%): 104.2/93.8, V150 (%): 53.8/47, respectively). No significant difference in migration of seeds was detected between loose and stranded seeds considering age (p = 0.33), PSA (p = 0.391), prostate volume (p = 0.397), activity of radioactive seeds (p = 0.109), number of seeds (p = 0.338), V100 (p = 0.332), although significant differences were measured in the values of D90(% and Gy) (p = 0.022 and 0.011) and V150 (p = 0.023).

CONCLUSIONS

Seed migration after brachytherapy might occur and it does affect post-implant dosimetry.

Clinical application and validation of an iterative forward projection matching algorithm for permanent brachytherapy seed localization from conebeam-CT x-ray projections

PURPOSE

To experimentally validate a new algorithm for reconstructing the 3D positions of implanted brachytherapy seeds from postoperatively acquired 2D conebeam-CT (CBCT) projection images.

METHODS

The iterative forward projection matching (IFPM) algorithm finds the 3D seed geometry that minimizes the sum of the squared intensity differences between computed projections of an initial estimate of the seed configuration and radiographic projections of the implant. In-house machined phantoms, containing arrays of 12 and 72 seeds, respectively, are used to validate this method. Also, four 103Pd postimplant patients are scanned using an ACUITY digital simulator. Three to ten x-ray images are selected from the CBCT projection set and processed to create binary seed-only images. To quantify IFPM accuracy, the reconstructed seed positions are forward projected and overlaid on the measured seed images to find the nearest-neighbor distance between measured and computed seed positions for each image pair. Also, the estimated 3D seed coordinates are compared to known seed positions in the phantom and clinically obtained VariSeed planning coordinates for the patient data.

RESULTS

For the phantom study, seed localization error is (0.58 +/- 0.33) mm. For all four patient cases, the mean registration error is better than 1 mm while compared against the measured seed projections. IFPM converges in 20-28 iterations, with a computation time of about 1.9-2.8 min/ iteration on a 1 GHz processor.

CONCLUSIONS

The IFPM algorithm avoids the need to match corresponding seeds in each projection as required by standard back-projection methods. The authors' results demonstrate approximately 1 mm accuracy in reconstructing the 3D positions of brachytherapy seeds from the measured 2D projections. This algorithm also successfully localizes overlapping clustered and highly migrated seeds in the implant.

A program for the independent verification of brachytherapy planning system calculations

Purpose

In this work a spreadsheet based program is presented that to a large extent independently verifies the calculations of individual plans of brachytherapy treatment planning systems for low dose rate, high dose rate and pulsed dose rate techniques.

Material and methods

The verification program has been developed based on workbooks/spreadsheets. The treatment planning system output text files are automatically loaded into the new program, allowing the use of the source coordinates, the desired calculation point coordinates, and the dwell times of a patient plan. The source strength and the reference dates are entered by the user and then dose points calculations are independently performed. The program shows its results in a comparison of its calculated point dose data with the corresponding TPS outcome.

Results

Results of 250 clinical cases show agreement with the TPS outcome within a 2% level.

Conclusions

The program allows the implementation of the recommendations to verify the clinical brachytherapy dosimetry in a simple and accurate way, in only few minutes and with a minimum of user interactions.

Image fusion techniques in permanent seed implantation

Over the last twenty years major software and hardware developments in brachytherapy treatment planning, intraoperative navigation and dose delivery have been made. Image-guided brachytherapy has emerged as the ultimate conformal radiation therapy, allowing precise dose deposition on small volumes under direct image visualization. In this process imaging plays a central role and novel imaging techniques are being developed (PET, MRI-MRS and power Doppler US imaging are among them), creating a new paradigm (dose-guided brachytherapy), where imaging is used to map the exact coordinates of the tumour cells, and to guide applicator insertion to the correct position. Each of these modalities has limitations providing all of the physical and geometric information required for the brachytherapy workflow. Therefore, image fusion can be used as a solution in order to take full advantage of the information from each modality in treatment planning, intraoperative navigation, dose delivery, verification and follow-up of interstitial irradiation. Image fusion, understood as the visualization of any morphological volume (i.e. US, CT, MRI) together with an additional second morphological volume (i.e. CT, MRI) or functional dataset (functional MRI, SPECT, PET), is a well known method for treatment planning, verification and follow-up of interstitial irradiation. The term image fusion is used when multiple patient image datasets are registered and overlaid or merged to provide additional information. Fused images may be created from multiple images from the same imaging modality taken at different moments (multi-temporal approach), or by combining information from multiple modalities. Quality means that the fused images should provide additional information to the brachytherapy process (diagnosis and staging, treatment planning, intraoperative imaging, treatment delivery and follow-up) that cannot be obtained in other ways. In this review I will focus on the role of image fusion for permanent seed implantation.

Localized prostate cancer with intermediate- or high-risk features treated with combined external beam radiotherapy and iodine-125 seed brachytherapy

OBJECTIVE

The aim of the study is to compare the results of the combined external beam radiotherapy (EBRT) with iodine-125 seed brachytherapy vs. brachytherapy alone for prostate cancer treatment in patients with intermediate and high risk of disease recurrence.

METHODS AND MATERIALS

Ninety-six patients were treated from January 1998 to December 2006. Twenty-four patients received combined treatment and 72 patients received brachytherapy alone. Patients were classified into intermediate or high risk of recurrence according to the D'Amico's classification. The prescribed dose for brachytherapy was 145Gy as monotherapy and 110Gy for combined treatment. The dose of EBRT was 45Gy over 5 weeks, with 1.8Gy daily fractions. Results were analyzed based on Phoenix definition of biochemical recurrence, that is, nadir plus 2ng/mL.

RESULTS

Biochemical control was achieved by 96% (23 of 24) of patients receiving combined treatment and by 72% (52 of 72) in the group treated by brachytherapy alone (p<0.015). The addition of EBRT resulted in a 94% biochemical disease-free survival at 5 years; and in brachytherapy alone group, the rate was 54% (p<0.011). Mean followup was 96 months (24-132 months; confidence interval 95%: 90-102).

CONCLUSION

This study shows that in patients with localized prostate cancer, with intermediate and high risk of biochemical recurrence, the addition of EBRT can confer a significant biochemical control advantage when added to brachytherapy.

Differential dose contributions on total dose distribution of (125)I brachytherapy source

This work provides an improvement of the approach using Monte Carlo simulation for the Amersham Model 6711 (125)I brachytherapy seed source, which is well known by many theoretical and experimental studies. The source which has simple geometry was researched with respect to criteria of AAPM Tg-43 Report. The approach offered by this study involves determination of differential dose contributions that come from virtual partitions of a massive radioactive element of the studied source to a total dose at analytical calculation point. Some brachytherapy seeds contain multi-radioactive elements so the dose at any point is a total of separate doses from each element. It is momentous to know well the angular and radial dose distributions around the source that is located in cancerous tissue for clinical treatments. Interior geometry of a source is effective on dose characteristics of a distribution. Dose information of inner geometrical structure of a brachytherapy source cannot be acquired by experimental methods because of limits of physical material and geometry in the healthy tissue, so Monte Carlo simulation is a required approach of the study. EGSnrc Monte Carlo simulation software was used. In the design of a simulation, the radioactive source was divided into 10 rings, partitioned but not separate from each other. All differential sources were simulated for dose calculation, and the shape of dose distribution was determined comparatively distribution of a single-complete source. In this work anisotropy function was examined also mathematically.

Evaluation of the dosimetric parameters for 125I brachytherapy determined in prostate medium using CT images

In the present study, the prostate medium determined from the CT images of 149 patients was developed. The dosimetric parameters such as Λ, g(L)(r) and F(r, θ) used in TG-43U1-based calculation for an iodine-125 ((125)I) brachytherapy-source were examined using Monte Carlo code Geant4. Clinical dosimetry parameters such as the D(90) were evaluated among a subgroup of 50 randomly selected patients who had been treated with permanent brachytherapy between January 2008 and December 2008 at the Tokyo Medical Center. The results show a slight difference in the dose rate constant Λ (within 1.0%). The radial dose function g(L)(r) exhibits a prominent difference in the region over 3 cm, and this difference is maintained within 2.9% in the region close to the source. The calculated values of F(r, θ) for the prostate medium were similar to values for water (within 1%), except in the longitudinal axis. A comparison of D(90) values shows a systematic dose overestimation of 2.8 ± 0.7 Gy in water, where the distribution of the differences can be seen with a spread of 1.8 ± 0.3% compared to that in prostate medium. It was concluded that the introduction of any kind of tissue correction for the TG-43U1-based calculation was not necessary to allow for the differences in elemental compositions and densities between water and prostate medium. PACS number: 87.00.00; 87.55.dk; 87.55.K-; 87.56.B-.

Verification of air-kerma strength of 125I seed for permanent prostate implants in Japan

BACKGROUND

To assure the physical quality of brachytherapy, we investigated the difference between measured and manufacturer's stated source strengths in a single model SourceTech Medical (STM)1251 (125)I seed.

METHODS

A well-type ionization chamber with a single-seed holder was used to measure the source strength of 2412 (125)I seeds before implant in 34 patients. The air-kerma strength was 0.450 U for all cases. The mean source strength for each patient was measured and compared with the manufacturer's stated value. The deviation from the measured value was compared with the tolerance range of the American Association of Physicists in Medicine (AAPM) TG-56 report's recommendation.

RESULTS

The measured source strength was higher than the manufacturer's stated value, with a median difference of 1% (range, 2% to 5%). Sixteen of the total of 2412 seeds (0.7%) were more than 5% different from the manufacturer's stated value. The median SD from the mean value was 2.2% (range, 1.1% to 2.5%) for all patients.

CONCLUSION

This is the first report of a single-seed assay performed for the model STM1251 (125)I seed. In this study the manufacturer's stated strength agreed well with the measured value. Nevertheless, the advisability of performing a single-seed assay at every institution should be considered, by referring to the appropriate regulations; for example, those used in the United States.

Physical derivation of nomograms in permanent prostate brachytherapy

PURPOSE

To demonstrate the physical origin of nomograms in permanent prostate brachytherapy, by using the correlation between fractional integral target dose (FITD) and target volume.

METHODS AND MATERIALS

The integral dose (ID) E delivered by unit activity is given by the integration of 4pi r(2)D(r)/r(2)dr x 1.44T(1/2) using the point source model from AAPM TG43. If A is the total activity implanted, then total ID will be AxE. Integral target dose are obtained by multiplying the prostate volume V with mean dose D(mean) by definition, assuming prostate gland has a unity density. The FITD the target receives is defined as FITD=D(mean)V/AE by energy conservation in the target volume. From this equation, the total activity needed to achieve given dose for a target of volume V is obtained. Results are compared with existing nomograms for (125)I and (103)Pd, and available clinical data for (131)Cs.

RESULTS

Agreement within 10.0% for (125)I and (103)Pd compared with existing nomograms for gland sizes from 18 to 80 cc is observed. For (131)Cs, the agreement is within 8.0% compared with available clinical data.

CONCLUSIONS

It is shown that the correlation between the FITD and target volume can be used to obtain the total activity needed to achieve prescribed dose. This correlation is inherent rather than empirical. It suggests that the correlation between fraction of energy deposition in target and target volume is the underlying physical origin for nomograms used in permanent prostate brachytherapy.

The biological effect of 125I seed continuous low dose rate irradiation in CL187 cells

Background

To investigate the effectiveness and mechanism of ¹²⁵I seed continuous low-dose-rate irradiation on colonic cell line CL187 in vitro.

Methods

The CL187 cell line was exposed to radiation of ⁶⁰Coγ ray at high dose rate of 2 Gy/min and ¹²⁵I seed at low dose rate of 2.77 cGy/h. Radiation responses to different doses and dose rates were evaluated by colony-forming assay. Under ¹²⁵I seed low dose rate irradiation, a total of 12 culture dishes were randomly divided into 4 groups: Control group, and 2, 5, and 10 Gy irradiation groups. At 48 h after irradiation, apoptosis was detected by Annexin and Propidium iodide (PI) staining. Cell cycle arrests were detected by PI staining. In order to investigate the influence of low dose rate irradiation on the MAPK signal transduction, the expression changes of epidermal growth factor receptor (EGFR) and Raf under continuous low dose rate irradiation (CLDR) and/or EGFR monoclonal antibodies were determined by indirect immunofluorescence.

Results

The relative biological effect (RBE) for ¹²⁵I seeds compared with ⁶⁰Co γ ray was 1.41. Apoptosis rates of CL187 cancer cells were 13.74% ± 1.63%, 32.58% ± 3.61%, and 46.27% ± 3.82% after 2 Gy, 5 Gy, and 10 Gy irradiation, respectively; however, the control group apoptosis rate was 1.67% ± 0.19%. G₂/M cell cycle arrests of CL187 cancer cells were 42.59% ± 3.21%, 59.84% ± 4.96%, and 34.61% ± 2.79% after 2 Gy, 5 Gy, and 10 Gy irradiation, respectively; however, the control group apoptosis rate was 26.44% ± 2.53%. P < 0.05 vs. control groups by Student's t-test were found in every treated group both in apoptosis and in G₂/M cell cycle arrest. After low dose rate irradiation, EGFR and Raf expression increased, but when EGFR was blocked by a monoclonal antibody, EGFR and Raf expression did not change.

Conclusion

¹²⁵I seeds resulted in more effective inhibition than ⁶⁰Co γ ray high dose rate irradiation in CL187 cells. Apoptosis following G₂/M cell cycle arrest was the main mechanism of cell-killing effects under low dose rate irradiation. CLDR could influence the proliferation of cells via MAPK signal transduction.

Vibro-acoustography imaging applications for the prostate

Vibro-acoustography (VA) is a novel modality that has shown significant features in imaging hard inclusions and inhomogeneities within biological tissue. Here we focus on its applications for prostate imaging as well as some of its related feasibility studies to guide minimally-invasive therapies such as brachytherapy and cryosurgery.

Quality assurance of radiotherapy in cancer treatment: toward improvement of patient safety and quality of care

The process of radiotherapy (RT) is complex and involves understanding of the principles of medical physics, radiobiology, radiation safety, dosimetry, radiation treatment planning, simulation and interaction of radiation with other treatment modalities. Each step in the integrated process of RT needs quality control and quality assurance (QA) to prevent errors and to give high confidence that patients will receive the prescribed treatment correctly. Recent advances in RT, including intensity-modulated and image-guided RT, focus on the need for a systematic RTQA program that balances patient safety and quality with available resources. It is necessary to develop more formal error mitigation and process analysis methods, such as failure mode and effect analysis, to focus available QA resources optimally on process components. External audit programs are also effective. The International Atomic Energy Agency has operated both an on-site and off-site postal dosimetry audit to improve practice and to assure the dose from RT equipment. Several countries have adopted a similar approach for national clinical auditing. In addition, clinical trial QA has a significant role in enhancing the quality of care. The Advanced Technology Consortium has pioneered the development of an infrastructure and QA method for advanced technology clinical trials, including credentialing and individual case review. These activities have an impact not only on the treatment received by patients enrolled in clinical trials, but also on the quality of treatment administered to all patients treated in each institution, and have been adopted globally; by the USA, Europe and Japan also.

Current brachytherapy quality assurance guidance: does it meet the challenges of emerging image-guided technologies?

In the past decade, brachytherapy has shifted from the traditional surgical paradigm to more modern three-dimensional image-based planning and delivery approaches. The role of intraoperative and multimodality image-based planning is growing. Published American Association of Physicists in Medicine, American College of Radiology, European Society for Therapeutic Radiology and Oncology, and International Atomic Energy Agency quality assurance (QA) guidelines largely emphasize the QA of planning and delivery devices rather than processes. These protocols have been designed to verify compliance with major performance specifications and are not risk based. With some exceptions, complete and clinically practical guidance exists for sources, QA instrumentation, non-image-based planning systems, applicators, remote afterloading systems, dosimetry, and calibration. Updated guidance is needed for intraoperative imaging systems and image-based planning systems. For non-image-based brachytherapy, the American Association of Physicists in Medicine Task Group reports 56 and 59 provide reasonable guidance on procedure-specific process flow and QA. However, improved guidance is needed even for established procedures such as ultrasound-guided prostate implants. Adaptive replanning in brachytherapy faces unsolved problems similar to that of image-guided adaptive external beam radiotherapy.

Quality assurance issues for computed tomography-, ultrasound-, and magnetic resonance imaging-guided brachytherapy

The requirements of quality assurance (QA) for both brachytherapy and imaging devices are well-defined, but image-guided brachytherapy has raised new issues. Image guidance in brachytherapy involves the transition from reference point dosimetry using films to volumetric imaging such as computed tomography, ultrasonography, and magnetic resonance imaging for treatment planning and guidance of applicator, needle, or seed placement. The QA of these devices might not reflect the conditions of use in brachytherapy or the requirements of brachytherapy treatment planning. Image interpretation becomes much more important with image-guided brachytherapy. The success of a procedure could depend on the interpretation of a single image in a calibration phase done under the time pressures of the operative setting. This change has implications at the level of treatment, the process, and the field of brachytherapy as a whole. The QA concerns arising from brachytherapy procedures using ultrasound, computed tomography, and magnetic resonance imaging guidance are discussed, as are the problems associated with using imaging in an interventional setting. This report was intended to indicate the QA concerns arising from the convergence of brachytherapy and imaging-highlighting areas in which technical improvements are needed.