Semiautomatic segmentation for prostate brachytherapy: Dosimetric evaluation

PurposeTo demonstrate that manual prostate segmentation in transrectal ultrasound images can be replaced with semiautomatic segmentation.Methods and MaterialsSemiautomatic segmentation using a tapered ellipsoid model was applied to transrectal ultrasound images. Region-based volumetric evaluation was performed between original and physician-reviewed semiautomatic contours. For dosimetric assessment, treatment plans generated on semiautomatic contours were overlaid on physician-reviewed semiautomatic contours and dose parameters were computed. To establish a threshold for the acceptable amount of dosimetric degradation below which the adoption of semiautomatic planning is unacceptable, the range of variability in dosimetric quality attributed to manual variability was obtained and compared with that of semiautomatic contours.ResultsAn average volume error (1—Dice similarity coefficient) of less than 7% between semiautomatic and manual volumes (140 cases) was obtained. The difference between the mean V₁₀₀ of plans created for semiautomatic contours then overlaid on physician-reviewed semiautomatic contours and the original V₁₀₀ values, that is, before overlaying on the physician-reviewed contours (41 cases) was lower than 5%. An average total duration of 2–4 min, which includes algorithm initialization, 11.67 ± 3.57 s algorithm time, and contour modification is required per case. This algorithm is being used at the British Columbia Cancer Agency and to this date has been applied for the treatment of more than 600 patients.ConclusionsIn terms of volumetric and dosimetric accuracy, the proposed algorithm is a suitable replacement for manual segmentation in the context of our planning technique. The benefits are shorter segmentation times; greater consistency; less reliance on user experience; and smooth, symmetric contours.     

Dosimetric effect of interfractional needle displacement in prostate high-dose-rate brachytherapy

PurposeTo quantify the dosimetric deviations that would arise from delivering subsequent prostate high-dose-rate fractions with only needle readjustment and no replanning after the first fraction.Methods and MaterialsPatients were treated with either two implant sessions (two 9.5-Gy fractions per session) separated by 2–4 weeks or with one implant session and external beam radiotherapy. After needle placement, needle positions were adjusted under CT guidance, after which dosimetric planning was performed before each fraction. To evaluate the consequence of not replanning before the second fraction, we analyzed the dosimetric parameters of 45 consecutive implants (26 patients). Needles with optimized dwell positions from the first fraction were transferred to the needle positions in the second fraction. Needle displacement between fractions was assessed as well as changes in plan metrics.ResultsAfter adjustment, the mean interfractional needle displacement was 3.5 mm. If replanned, the probability of planning target volume D_90% ≥95% is 100%, prostate V_100% ≥95% is 87%, and urethra V₁₁₅% ≤10% is 78%. If treated without replanning, the probability of planning target volume D_90% ≥95% is 82%, prostate V_100% ≥95% is 53%, and urethra V_115% ≤10% is 69%. Even for implants with minimal needle displacement (<3 mm) and minimal prostate volume change (<3 cc), the dosimetric consequence of not replanning the second fraction would result in 46% of cases with a prostate V_100% <95%.ConclusionThe dosimetric consequences of not replanning the second fraction for prostate high-dose-rate implants results in significantly inferior plan metrics.     

Dosimetric characteristics of 192Ir sources used in interstitial brachytherapy.

Dosimetric quantities of 192Ir seed (5 mm length) and wire (10 mm length) brachytherapy sources have been determined. The quantities were measured based on the protocol introduced by the Radiation Therapy Committee of the American Association of Physicists in Medicine (AAPM) Task Group 43. Quantities such as dose rate constant, (lambda), radial dose function, g(r), and anisotropy function, F(r, theta) were experimentally determined and the geometry function, G(r, theta), was calculated. TLD measurements were made in a polymethyl methacrylate (PMMA) phantom of dimensions 25 cm x 20 cm x 5 cm by means of LiF:Mg,Ti (TLD-100) dosimeters for distances of 1-10 cm for g(r), and the same distances at angles of 0-180 degrees for F(r, theta). Dose rate constant for 192Ir seed and wire were found to be 1.196+/-5 and 1.082+/-5% cGy h(-1) U(-1), respectively (1 U = unit of air Kerma strength = 1 microGy m2 h(-1) = 1 cGy cm2 h(-1)). The obtained results for g(r), G(r, theta) and F(r, theta) are also presented and discussed.     

Dosimetric characterization of 142Pr glass seeds for brachytherapy.

A glass bead consisted of the beta(-)-emitting (142)Pr is proposed for brachytherapy treatment of prostate cancer. Appropriate radionuclide and seed dimensions were selected and sample seeds were manufactured. For the quantitative dosimetric parameters, two-dimensional dose distributions were calculated using the MCNP5 Monte Carlo code and measured using radiochromic film. The computational results compared well with measurements. Dose at 0.6 cm from the seed center can exceed 130 Gy. The reference dose rate, radial dose function and the anisotropy function were derived.     

Dosimetric consequences of seed placement accuracy in permanent breast seed implant brachytherapy

PurposeThis study quantifies the dosimetric impact of implant accuracy and derives a quantitative relationship relating implant accuracy to target dosimetry.Methods and MaterialsA framework was developed to simulate multiple implants for error combinations. Spherical clinical target volumes (CTVs) were modeled with volumes 1.4 cm³, 9.2 cm³, and 20.6 cm³, representing the range seen clinically. Each CTV was expanded 10 mm isotropically to create a planning target volume (PTV).. Random and systematic seed placement errors were simulated by shifting needles from their planned positions. Implant errors were simulated over the range of clinically practical errors in permanent breast seed implant. The relative effect on target coverage was evaluated. Regression analysis was performed to derive relationships between CTV dosimetry and the magnitude of implant accuracy. The validity of the clinically used 10 mm PTV margin for each of the CTVs was assessed.ResultsIntroducing practical implant errors resulted in CTV V_90% median (10th and 90th percentile) of 97.7% (85.9% and 100%), 96.2% (86.8% and 99.7%), and 100% (77.8% and 100%) for the typical, large, and small CTV, respectively. All CTVs show similar trends in target coverage. Polynomials were derived relating seed placement accuracy to median (R² = 0.82) and 10th percentile (R² = 0.78) CTV V_90%._.ConclusionsThis work quantitatively describes the relationship between implant accuracy and CTV coverage. Based on simulations, the 10 mm PTV margin is adequate to maintain target coverage. These equations can be used with institutional seed placement accuracy to estimate coverage.     

Dosimetric and clinical outcome in image-based high-dose-rate interstitial brachytherapy for anal cancer

PurposeTo evaluate dosimetric and clinical outcome in patients of anal cancer treated with image-based interstitial high-dose-rate brachytherapy following chemoradiation.Methods and MaterialsSixteen patients with anal cancer were treated with chemoradiation followed by brachytherapy boost with image-based high-dose-rate interstitial brachytherapy from January 2007 to June 2011. Two brachytherapy dose schedules were used: 21 Gy in seven fractions and 18 Gy in six fractions depending on response to chemoradiation. CT scan was done after placement of needles for confirmation of placement and treatment planning. Target volume was contoured on CT scans. Volumetric quality indices and dose parameters were calculated.ResultsThe mean clinical target volume was 17.7 ± 4.98 cm³, and the median overall tumor size was 4.2 cm (3.4–5 cm). The mean values of coverage index, dose homogeneity index, overdose volume index, dose non-uniformity ratio, and conformal index were 0.94, 0.83, 0.21, 0.37, and 0.88, respectively. With a median followup of 41 months (range, 20–67.2 months), preservation of the anal sphincter was achieved in 14 patients. The 1- and 2-year local control rates were 93.8% and 87.5%, respectively. Treatment was well tolerated and none of the patients developed Grade 3 or higher late toxicity.ConclusionsThe combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and limits the volume of irradiated normal tissue, thereby decreasing late toxicity. The use of image-based treatment planning provides better dose conformality with reduced toxicity and helps to prevent a geographic miss.     

Dosimetric influence of seed spacers and end-weld thickness for permanent prostate brachytherapy

PurposeThe aim of this study was to analyze the dosimetric influence of conventional spacers and a cobalt chloride complex contrast (C4) agent, a novel marker for MRI that can also serve as a seed spacer, adjacent to ¹⁰³Pd, ¹²⁵I, and ¹³¹Cs sources for permanent prostate brachytherapy.Methods and MaterialsMonte Carlo methods for radiation transport were used to estimate the dosimetric influence of brachytherapy end-weld thicknesses and spacers near the three sources. Single-source assessments and volumetric conditions simulating prior patient treatments were computed. Volume–dose distributions were imported to a treatment planning system for dose–volume histogram analyses.ResultsSingle-source assessment revealed that brachytherapy spacers primarily attenuated the dose distribution along the source long axis. The magnitude of the attenuation at 1 cm on the long axis ranged from −10% to −5% for conventional spacers and approximately −2% for C4 spacers, with the largest attenuation for ¹⁰³Pd. Spacer perturbation of dose distributions was less than manufacturing tolerances for brachytherapy sources as gleaned by an analysis of end-weld thicknesses. Volumetric Monte Carlo assessment demonstrated that TG-43 techniques overestimated calculated doses by approximately 2%. Specific dose–volume histogram metrics for prostate implants were not perturbed by inclusion of conventional or C4 spacers in clinical models.ConclusionsDosimetric perturbations of single-seed dose distributions by brachytherapy spacers exceeded 10% along the source long axes adjacent to the spacers. However, no dosimetric impact on volumetric parameters was noted for brachytherapy spacers adjacent to ¹⁰³Pd, ¹²⁵I, or ¹³¹Cs sources in the context of permanent prostate brachytherapy implants.     

Dosimetric study of CO-60 source step size in uterine cervix intracavitary HDR brachytherapy

Purpose

The present work reports effects of source step sizes on dose distribution in patients treated with cobalt-60 (Co-60) high-dose-rate afterloading brachytherapy in carcinoma cervix (Ca-cx).

江苏省核查放射治疗参考与非参考条件下剂量学参数方法验证

目的 研究用热释光剂量计（TLD）方法核查放射治疗参考条件和非参考条件下剂量学参数的可靠性验证。方法 在参考条件和非参考条件下,用建立的TLD方法,核查5家医院的10条6 MV光子线束剂量随深度、源皮距离、照射野大小和45°楔形板等变化,5条9 MeV电子线束轴向最大剂量点处等剂量学参数,TLD估算结果与剂量仪测量结果进行对比。结果 6 MV 光子线束轴上非参考条件和离轴非参考条件下的TLD监测结果与指型电离室监测结果的相对偏差范围分别为-1.7%~5.4%、-6.3%~-0.6%,符合IAEA要求的≤±7%;电子射线束TLD估算结果与平行板电离室测量结果相对偏差范围为-2.3%~3.7%,符合IAEA要求的≤±5%。结论 用TLD核查参考条件和非参考条件下放射治疗剂量学参数方法可靠,简单易行。     

Dosimetric characterization of a brachytherapy applicator using MCNP5 modelisation and in-phantom measurements

A gynaecological applicator consisting of a metallic intra-uterine tube with a plastic vaginal applicator and an HDR Ir-192 source have been simulated with MCNP5 (Monte Carlo code). A solid phantom has been designed to perform measurements around the applicator with radiochromic films. The isodose curves obtained are compared with curves calculated with the F4MESH tally of MCNP5 with a good agreement. A pinpoint ionization chamber has been used to evaluate dose at some reference points.     

Dosimetric effect of external beam planning preceding combined high-dose-rate brachytherapy of the prostate

Purpose

The sequencing of external beam radiotherapy (EBRT) and a high-dose-rate brachytherapy (HDRB) boost is often interchangeable in clinical practice. When given before EBRT, HDRB could induce volume alterations in the prostate, which may have significant implications for EBRT dosimetry. We aimed to assess the influence of HDRB on prostate volume and, hence, prostate dosing via subsequent EBRT.

Methods and Materials

Fifteen men had both pre- and post-HDRB CT performed followed by EBRT. After deidentification, the clinical target volume (CTV) was defined on each CT by a single-blinded observer. Volumes were compared for the pre- and post-HDRB scans in each patient. Radiotherapy planning was performed using the prebrachytherapy volumes aiming for the planning target volume (PTV) to be covered by 43.7 Gy. After soft-tissue coregistration, this plan was also applied to the postbrachytherapy volumes.

Results

Median volume increase was 35.4% for the CTV after HDRB. No patient experienced a decrease in CTV volume (range, 0-79% volume increase; p-value < 0.001). Median volume increase was 26.1% for the PTVs, with no volume decrease observed (range, 8-56%; p < 0.001). PTV proportion achieving dose target (V43.7 Gy) decreased by median of 7% (range, 0-21.5%; p = 0.004). The minimum dose to the PTV (D₁₀₀%) decreased by a median of 6 Gy (range, 0.5-16 Gy; p < 0.001).

Conclusions

Insertion of HDRB catheters exerts substantial acute volumetric distortion on the prostate. EBRT planning performed on the basis of pre-HDRB imaging only inherently risks underdosing tumor. Planning adjustments based on repeat CT, or dedicated post-HDBT planning, is warranted for men managed with HDRB before EBRT.     

Dosimetric comparison of optimization methods for multichannel intracavitary brachytherapy for superficial vaginal tumors

PurposeMultichannel vaginal applicators allow treatment of a more conformal volume compared with a single, central vaginal channel. There are several optimization methods available for use with multichannel applicators, but no previous comparison of these has been performed in the treatment of superficial vaginal tumors. Accordingly, a feasibility study was completed to compare inverse planning by simulated annealing (IPSA), dose point optimization (DPO), and graphical optimization for high-dose-rate brachytherapy using a multichannel, intracavitary vaginal cylinder.Methods and MaterialsThis comparative study used CT data sets from five patients with superficial vaginal recurrences of endometrial cancer treated with multichannel intracavitary high-dose-rate brachytherapy. Treatment plans were generated using DPO, graphical optimization, surface optimization with IPSA (surf IPSA), and two plans using volume optimization with IPSA. The plans were evaluated for target coverage, conformal index, dose homogeneity index, and dose to organs at risk.ResultsBest target coverage was achieved by volume optimization with IPSA 2 and surf IPSA with mean V100 values of 93.89% and 91.87%, respectively. Doses for the most exposed 2-cm³ of the bladder (bladder D2cc) was within tolerance for all optimization methods. Rectal D2cc was above tolerance for one DPO plan. All volume optimization with IPSA plans resulted in higher vaginal mucosa doses for all patients. Greatest homogeneity within the target volume was seen with surf IPSA and DPO. Highest conformal indices were seen with surf IPSA and graphical optimization.ConclusionsOptimization with surf IPSA was user friendly for the generation of treatment plans and achieved good target coverage, conformity, and homogeneity with acceptable doses to organs at risk.     

Dosimetric and radiobiological investigation of permanent implant prostate brachytherapy based on Monte Carlo calculations

PurposePermanent implant prostate brachytherapy plays an important role in prostate cancer treatment, but dose evaluations typically follow the water-based TG-43 formalism, ignoring patient anatomy and interseed attenuation. The purpose of this study is to investigate advanced TG-186 model-based dose calculations via retrospective dosimetric and radiobiological analysis for a new patient cohort.Methods and MaterialsA cohort of 155 patients treated with permanent implant prostate brachytherapy from The Ottawa Hospital Cancer Centre is considered. Monte Carlo (MC) dose calculations are performed using tissue-based virtual patient models. Dose–volume histogram (DVH) metrics (target, organs at risk) are extracted from 3D dose distributions and compared with those from calculations under TG-43 assumptions (TG43). Equivalent uniform biologically effective dose and tumor control probability are calculated.ResultsFor the target, D₉₀ (V₁₀₀) is 136.7 ± 20.6 Gy (85.8% ± 7.8%) for TG43 and 132.8 ± 20.1 Gy (84.1% ± 8.2%) for MC; D₉₀ is 3.0% ± 1.1% lower for MC than TG43. For organs at risk, MC D_1cc = 104.4 ± 27.4 Gy (TG43: 106.3 ± 28.3 Gy) for rectum and 80.8 ± 29.7 Gy (TG43: 78.4 ± 28.4 Gy) for bladder; D_1cc = 185.9 ± 30.2 Gy (TG43: 191.1 ± 32.0 Gy) for urethra. Equivalent uniform biologically effective dose and tumor control probability are generally lower when evaluated using MC doses. The largest dosimetric and radiobiological discrepancies between TG43 and MC are for patients with intraprostatic calcifications, for whom there are low doses (cold spots) in the vicinity of calcifications within the target, identified with MC but not TG43.ConclusionsDVH metrics and radiobiological indices evaluated with TG43 are systematically inaccurate by upward of several percent compared with MC patient-specific models. Mean cohort DVH metrics and their MC:TG43 variances are sensitive to patient cohort and clinical practice, underlining the importance of further retrospective MC studies toward widespread clinical adoption of advanced model-based dose calculations.     

Dosimetric investigation of LDR brachytherapy 192Ir wires by Monte Carlo and TPS calculations

Purpose

The aim of this study was to investigate the dose rate distribution around ¹⁹²Ir wires used as radioactive sources in low-dose-rate brachytherapy applications.

Materials and methods

Monte Carlo modeling of a 0.3-mm diameter source and its surrounding water medium was performed for five different wire lengths (1–5 cm) using the MCNP software package.

Results

The computed dose rates per unit of air kerma at distances from 0.1 up to 10 cm away from the source were first verified with literature data sets. Then, the simulation results were compared with the calculations from the XiO CMS commercial treatment planning system.

Conclusion

The study results were found to be in concordance with the treatment planning system calculations except for the shorter wires at close distances.     

Dosimetric investigation of 103Pd permanent breast seed implant brachytherapy based on Monte Carlo calculations

PurposePermanent breast seed implant using ¹⁰³Pd is emerging as an effective adjuvant radiation technique for early stage breast cancer. However, clinical dose evaluations follow the water-based TG-43 approach with its considerable approximations. Toward clinical adoption of advanced TG-186 model-based dose evaluations, this study presents a comprehensive investigation for permanent breast seed implant considering both target and normal tissue doses.Methods and MaterialsDose calculations are performed with the free open-source Monte Carlo (MC) code, egs_brachy, using two types of virtual patient models: TG43sim (simulated TG-43 conditions) and MCref (heterogeneous tissue modeling from patient CT, seeds at implant angle) for 35 patients. The sensitivity of dose metrics to seed orientation and tissue segmentation are assessed.ResultsIn the target volume, D₉₀ is 14.1 ± 5.8% lower with MCref than with TG43sim, on average. Conversely, normal tissue doses are generally higher with MCref than with TG43sim, for example, by 22 ± 13% for skin D_1cm2, 82 ± 7% for ribs D_max, and 71 ± 23% for heart D_1cm3. Discrepancies between MCref and TG43sim doses vary over the patient cohort, as well as with the tissue and metric considered. Skin doses are particularly sensitive to seed orientation, with average difference of 4% (maximum 28%) in D_1cm2 for seeds modeled vertically (egs_brachy default) compared with those aligned with implant angle.ConclusionsTG-43 dose evaluations generally underestimate doses to critical normal organs/tissues while overestimating target doses. There is considerable variation in MCref and TG43sim on a patient-by-patient basis, motivating clinical adoption of patient-specific MC dose calculations. The MCref framework presented herein provides a consistent modeling approach for clinical implementation of advanced TG-186 dose calculations.     

Dosimetric characterization of an encapsulated interstitial brachytherapy source of 125I on a tungsten substrate

PURPOSE: Recently, a new design of an encapsulated 125I source using a tungsten substrate has been introduced by Best Medical International and named as Best Model 2301 source. In contrast to model 6711 source that uses silver as substrate, the model 2301 source does not yield fluorescent x rays (22.1 keV and 25.5 keV) in the energy range of dosimetric interest. This changes the dosimetric characteristics of the source and experimental determination of these characteristics is needed. METHODS AND MATERIALS: In this work, the dosimetric characteristics of the tungstenbased 125I source were measured using LiF TLDs in a Solid Water phantom. The dose rate constant as well as the radial dose function and anisotropy function were measured. RESULTS: The dose rate constant for the tungsten-based source was determined to be 1.02 +/- 0.07 cGy h(-1) U(-1) in contrast to the previously reported value of 0.98 for the silver-based model 6711 source. The radial dose function for the tungsten-based model 2301 source decreases slightly less rapidly with distance than that for the silver-based model 6711 source. Considerable differences in the anisotropy functions between the two sources were observed. CONCLUSIONS: Dosimetric parameters of the Model 2301 source, based on AAPM TG-43 formalism, have been experimentally determined.