Radiotherapy dosimetry audit: three decades of improving standards and accuracy in UK clinical practice and trials

Dosimetry audit plays an important role in the development and safety of radiotherapy. National and large scale audits are able to set, maintain and improve standards, as well as having the potential to identify issues which may cause harm to patients. They can support implementation of complex techniques and can facilitate awareness and understanding of any issues which may exist by benchmarking centres with similar equipment. This review examines the development of dosimetry audit in the UK over the past 30 years, including the involvement of the UK in international audits. A summary of audit results is given, with an overview of methodologies employed and lessons learnt. Recent and forthcoming more complex audits are considered, with a focus on future needs including the arrival of proton therapy in the UK and other advanced techniques such as four-dimensional radiotherapy delivery and verification, stereotactic radiotherapy and MR linear accelerators. The work of the main quality assurance and auditing bodies is discussed, including how they are working together to streamline audit and to ensure that all radiotherapy centres are involved. Undertaking regular external audit motivates centres to modernize and develop techniques and provides assurance, not only that radiotherapy is planned and delivered accurately but also that the patient dose delivered is as prescribed.     

Analysis of regional radiotherapy dosimetry audit data and recommendations for future audits

Objectives

Regional interdepartmental dosimetry audits within the UK provide basic assurances of the dosimetric accuracy of radiotherapy treatments.

Methods

This work reviews several years of audit results from the South East Central audit group including megavoltage (MV) and kilovoltage (kV) photons, electrons and iodine-125 seeds.

Results

Apart from some minor systematic errors that were resolved, the results of all audits have been within protocol tolerances, confirming the long-term stability and agreement of basic radiation dosimetric parameters between centres in the audit region. There is some evidence of improvement in radiation dosimetry with the adoption of newer codes of practice.

Conclusion

The value of current audit methods and the limitations of peer-to-peer auditing is discussed, particularly the influence of the audit schedule on the results obtained, where no “gold standard” exists. Recommendations are made for future audits, including an essential requirement to maintain the monitoring of basic fundamental dosimetry, such as MV photon and electron output, but audits must also be developed to include new treatment technologies such as image-guided radiotherapy and address the most common sources of error in radiotherapy.There are numerous recommendations specifying that radiotherapy departments should take part in external quality control audits. These include radiation incident reports [1], guidance to improve safety in radiotherapy [2] and UK radiotherapy performance measures [3]. However, there is little evidence-based guidance as to the nature and scope of the required audits, their frequency and the achievable tolerance, nor a detailed analysis of the value of a substantial body of interdepartmental audit results or where auditing activity should be focused in the future. Indeed, the latest radiotherapy peer review measures [3] simply state that radiotherapy departments “should have taken part in the external quality control programme, as agreed by the network”, leaving individual networks to agree both the scope and the frequency of audit. The 2008 joint Royal College of Radiologists publication “Towards safer radiotherapy” [2] advocated the use of dosimetric audit networks.The South East Central Regional Audit Group (also known as Group E, and previously the Oxford Group) is the largest in the UK, now comprising 11 radiotherapy centres, listed in 4]. More importantly, the data are also used as a basis to make recommendations for future audits. Data from audits within the south east central region for specific clinical trials, or for ad hoc audits on new equipment installations, are not included in the analysis. However, data from the audit measurement programme of the National Physical Laboratory (NPL), Teddington, UK, are included when directly relevant to the interdepartmental audits.

Table 1

Radiotherapy departments within the South East Central Regional Audit Group

Experience of using MOSFET detectors for dose verification measurements in an end-to-end 192Ir brachytherapy quality assurance system

PurposeEstablishment of an end-to-end system for the brachytherapy (BT) dosimetric chain could be valuable in clinical quality assurance. Here, the development of such a system using MOSFET (metal oxide semiconductor field effect transistor) detectors and experience gained during 2 years of use are reported with focus on the performance of the MOSFET detectors.Methods and MaterialsA bolus phantom was constructed with two implants, mimicking prostate and head & neck treatments, using steel needles and plastic catheters to guide the ¹⁹²Ir source and house the MOSFET detectors. The phantom was taken through the BT treatment chain from image acquisition to dose evaluation. During the 2-year evaluation-period, delivered doses were verified a total of 56 times using MOSFET detectors which had been calibrated in an external ⁶⁰Co beam. An initial experimental investigation on beam quality differences between ¹⁹²Ir and ⁶⁰Co is reported.ResultsThe standard deviation in repeated MOSFET measurements was below 3% in the six measurement points with dose levels above 2 Gy. MOSFET measurements overestimated treatment planning system doses by 2–7%. Distance-dependent experimental beam quality correction factors derived in a phantom of similar size as that used for end-to-end tests applied on a time-resolved measurement improved the agreement.ConclusionsMOSFET detectors provide values stable over time and function well for use as detectors for end-to-end quality assurance purposes in ¹⁹²Ir BT. Beam quality correction factors should address not only distance from source but also phantom dimensions.     

Dosimetric Quality Assurance for Intensity–Modulated Radiotherapy

PURPOSE: Test and comparison of various 2-D real-time detectors for dosimetric quality assurance (QA) of intensity-modulated radiotherapy (IMRT) with the vision to replace radiographic films for 2-D dosimetry. MATERIAL AND METHODS: All IMRT treatment plans were created with the Konrad software (Siemens OCS). The final dose calculation was also carried out in Konrad. A Mevatron Primus (Siemens OCS) linear accelerator which provides 6-MV and 15-MV highenergy photon beams was used for the delivery of segmented multileaf-modulated IMRT. Three different 2-D detectors, each based on a different physical (interaction) principle, were tested for the field-related IMRT verification: (1) the MapCheck diode system (Sun Nuclear), (2) the I'mRT QA scintillation detector (Scanditronix/Wellh?fer), and the Seven29 ionization chamber array (PTW). The performance of these detector arrays was evaluated against IMRT dose distributions created and calculated with Konrad and the results obtained were compared with film measurements performed with radiographic films (EDR2, Kodak). Additionally, measurements were performed with point detectors, such as diamond, diodes (PTW) and ionization chambers (PTW, Scanditronics/ Wellh?fer) and radiochromic films (GafChromic film MD55, ISP). RESULTS: The results obtained with all three 2-D detector systems were in good agreement with calculations performed with the treatment-planning system and with the standard dosimetric tools, i.e., films or various point dose detectors. It could be shown that all three systems offer dosimetric characteristics required for performing field-related IMRT QA with relative dose measurements. The accuracy of the 2-D detectors was mostly +/- 3% normalized to dose maximum for a wide dynamic range. The maximum deviations did not exceed +/- 5% even in regions with a steep dose gradient. The main differences between the detector systems were the spatial resolution, the maximal field size, and the ability to perform absolute dosimetric measurements. CONCLUSION: Commercial 2-D detectors have the potential to replace films as an "area detector" for field-related verification of IMRT. The on-line information provided by the respective systems can even improve the efficiency of the QA procedures.     

A Dosimetric Comparison of IORT Techniques in Limited-Stage Breast Cancer

BACKGROUND AND PURPOSE: For intraoperative radiotherapy (IORT) during breast-conserving treatment four different techniques have been addressed: interstitial brachytherapy, an inflatable balloon with a central high-dose-rate source (MammoSite), a miniature orthovolt system (Intrabeam), and linac-based electron radiotherapy (IOERT). The dosimetric properties of these methods are compared. MATERIAL AND METHODS: Planning target volumes (PTVs) of the same size but of different shapes are assumed, corresponding to the technique's specific situs. Dose distributions for the PTVs and for surrounding tissues are demonstrated by dose-volume histograms and a list of physical parameters. A dose inhomogeneity index (DII) is introduced to describe the deviation of a delivered from the prescribed dose, reaching its minimal value 0 in case of perfect homogeneity. RESULTS: In terms of DII, IOERT reaches the lowest value followed by the MammoSite, the Intrabeam and interstitial implants. The surrounding tissues receive the smallest average dose with IOERT, closely followed by the orthovolt system. CONCLUSION: When comparing simplified geometric figures, IOERT delivers the most homogeneous dose distributions. However, in clinical reality PTVs often present asymmetric shapes instead of ideal geometries. Due to a strictly centric dose fall-off, any system with a round central applicator will have technical limits. During IOERT margin-directed applicator guidance is possible and interstitial brachytherapy allows for polygonal dose shaping. These techniques seem to be superior for asymmetric PTV irradiation.     

Brachytherapy: A critical component of primary radiation therapy for cervical cancer: From the Society of Gynecologic Oncology (SGO) and the American Brachytherapy Society (ABS)

Brachytherapy is well-established as an integral component in the standard of care for treatment of patients receiving primary radiotherapy for cervical cancer. A decline in brachytherapy has been associated with negative impacts on survival in the era of modern EBRT techniques. Conformal external beam therapies such intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT) should not be used as alternatives to brachytherapy in patients undergoing primary curative-intent radiation therapy for cervical cancer. Computed tomography or magnetic resonance image-guided adaptive brachytherapy is evolving as the preferred brachytherapy method. With careful care coordination EBRT and brachytherapy can be successfully delivered at different treatment centers without compromising treatment time and outcome in areas where access to brachytherapy maybe limited.     

Experience of high-dose-rate brachytherapy for head and neck cancer treated by a customized intraoral mold technique

Radiotherapy of head and neck cancer has become more successful with the advances in treatment modalities and use of a multidisciplinary approach. Higher quality treatment and a team approach to radiotherapy have thus been required for head and neck cancer. This study presents the clinical experience of high-dose-rate (HDR) brachytherapy for head and neck cancer treated by a customized intraoral mold technique. Two patients are reported for whom we created dental prostheses as the radiation carriers for HDR brachytherapy of their head and neck cancers. HDR brachytherapy with the dental prostheses reported here was feasible and effective for eradicating the head and neck cancer. It has been demonstrated that HDR brachytherapy using a customized intraoral technique can be a treatment option for patients who are not candidates for surgery or external irradiation. It is strongly suggested that specialized dentists are needed who are familiar with not only the anatomy and function of the head and neck region but also radiotherapy. Dental radiologists should take responsibility for constructing irradiation prostheses. If they do, they have the potential to improve the quality of life of patients who undergo radiotherapy for head and neck cancer.     

Preoperative treatment planning with intraoperative optimization can achieve consistent high-quality implants in prostate brachytherapy

Advances in brachytherapy treatment planning systems have allowed the opportunity for brachytherapy to be planned intraoperatively as well as preoperatively. The relative advantages and disadvantages of each approach have been the subject of extensive debate, and some contend that the intraoperative approach is vital to the delivery of optimal therapy. The purpose of this study was to determine whether high-quality permanent prostate implants can be achieved consistently using a preoperative planning approach that allows for, but does not necessitate, intraoperative optimization. To achieve this purpose, we reviewed the records of 100 men with intermediate-risk prostate cancer who had been prospectively treated with brachytherapy monotherapy between 2006 and 2009 at our institution. All patients were treated with iodine-125 stranded seeds; the planned target dose was 145 Gy. Only 8 patients required adjustments to the plan on the basis of intraoperative findings. Consistency and quality were assessed by calculating the correlation coefficient between the planned and implanted amounts of radioactivity and by examining the mean values of the dosimetric parameters obtained on preoperative and 30 days postoperative treatment planning. The amount of radioactivity implanted was essentially identical to that planned (mean planned radioactivity, 41.27 U vs. mean delivered radioactivity, 41.36 U; R² = 0.99). The mean planned and day 30 prostate V100 values were 99.9% and 98.6%, respectively. The mean planned and day 30 prostate D90 values were 186.3 and 185.1 Gy, respectively. Consistent, high-quality prostate brachytherapy treatment plans can be achieved using a preoperative planning approach, mostly without the need for intraoperative optimization. Good quality assurance measures during simulation, treatment planning, implantation, and postimplant evaluation are paramount for achieving a high level of quality and consistency.     

Real-time dosimetry in external beam radiation therapy

With growing complexity in radiotherapy treatment delivery, it has become mandatory to check each and every treatment plan before implementing clinically. This process is currently administered by an independent secondary check of all treatment parameters and as a pre-treatment quality assurance (QA) check for intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy treatment plans. Although pre-treatment IMRT QA is aimed to ensure the correct dose is delivered to the patient, it does not necessarily predict the clinically relevant patient dose errors. During radiotherapy, treatment uncertainties can affect tumor control and may increase complications to surrounding normal tissues. To combat this, image guided radiotherapy is employed to help ensure the plan conditions are mimicked on the treatment machine. However, it does not provide information on actual delivered dose to the tumor volume. Knowledge of actual dose delivered during treatment aid in confirming the prescribed dose and also to replan/reassess the treatment in situations where the planned dose is not delivered as expected by the treating physician. Major accidents in radiotherapy would have been averted if real time dosimetry is incorporated as part of the routine radiotherapy procedure. Of late real-time dosimetry is becoming popular with complex treatments in radiotherapy. Real-time dosimetry can be either in the form of point doses or planar doses or projected on to a 3D image dataset to obtain volumetric dose. They either provide entrance dose or exit dose or dose inside the natural cavities of a patient. In external beam radiotherapy, there are four different established platforms whereby the delivered dose information can be obtained: (1) Collimator; (2) Patient; (3) Couch; and (4) Electronic Portal Imaging Device. Current real-time dosimetric techniques available in radiotherapy have their own advantages and disadvantages and a combination of one or more of these methods provide vital information about the actual dose delivered to radiotherapy patients.     

A pragmatic approach to dosimetric audit in radiotherapy

In 1993 a dosimetric audit programme was initiated by physicists from a group of hospitals in the South West UK with the aim of detecting dosimetric errors greater than 5%. The scope of this programme was developed to cover megavoltage and kilovoltage photons as well as electrons. Procedures operated within each department were also audited in situations where they could influence dosimetry. No dose discrepancies greater than 5% were detected in the course of the audits, though differences did correlate with complexity in some situations. These measurements provide an ongoing assurance that dosimetry within the participating centres is well controlled and provides a firm foundation for clinical practice.     

Feasibility of improving patient’s safety with in vivo dose tracking in intracavitary and interstitial HDR brachytherapy

PurposeThe in vivo dosimetric monitoring in HDR brachytherapy is important for improving patient safety. However, there are very limited options available for clinical application. In this study, we present a new in vivo dose measurement system with a plastic scintillating detector (PSD) for GYN HDR brachytherapy.MethodsAn FDA approved PSD system, called OARtrac (AngioDynamics, Latham, NY), was used with various applicators for in vivo dose measurements for GYN patients. An institutional workflow was established for the clinical implementation of the dosimetric system. Action levels were proposed based on the measurement and system uncertainty for measurement deviations. From October 2018 to September 2019, a total of 75 measurements (48 fractions) were acquired from 14 patients who underwent HDR brachytherapy using either a multichannel cylinder, Venezia applicator, or Syed-Neblett template. The PSDs were placed in predetermined catheters/channels. A planning CT was acquired for treatment planning in Oncentra (Elekta, Version-4.5.2) TPS. The PSDs were contoured on the CT images, and the PSD D_90% values were used as the expected doses for comparison with the measured doses.ResultsThe mean difference from patient measurements was ?0.22% ± 5.98%, with 26% being the largest deviation from the expected value (Syed case). Large deviations were observed when detectors were placed in the area where dose rates were less than 1 cGy/s.ConclusionsThe establishment of clinical workflow for the in vivo dosimetry for both the intracavitary and interstitial GYN HDR brachytherapy will potentially improve the safety of the patient treatment.     

Penile brachytherapy: Technical aspects and postimplant issues

PurposeSquamous carcinoma (SCC) of the penis affects about 1 in 100,000 men in western societies. Interstitial brachytherapy can be an effective penis-conserving modality for T1, T2, and selected T3 tumors. Unfortunately, few radiation oncology trainees have the opportunity to treat a case of penile cancer during their residency, and few centers have brachytherapy expertise for this tumor site. We report our technique that has been developed and refined over the past 20 years.Materials and MethodsFrom 1989 to 2009, we have been using brachytherapy to treat penile SCC and have experience with 75 cases. From 1989 to 1998, manual afterloading was used with ¹⁹²Ir wire or seeds, and from 1999 to the present, pulse dose rate automated afterloading. Sixty Gray is delivered over a period of 4–5 days.ResultsPatient selection for penile brachytherapy and the technical and dosimetric aspects of the procedure will be discussed along with posttreatment care and followup.ConclusionsBrachytherapy is an effective treatment for T1, T2, and selected T3 SCC of the penis. Efficacy depends on careful planning and appreciation of dosimetry.     

Evaluation of the dose in permanent implants of I-125

The Anderson's nomograph is currently used in 125I implants planning. For a given treatment volume, this method provides the activity and the seeds number and spacing. In order to obtain indications of the dose delivered in that 125I volume implants, we computed the average peripheral dose (APD), the average tumor dose (ATD) and the "matched peripheral dose" (MPD), for spherical, ellypsoidal and cylindrical volumes. By using the 125I source dosimetric data, we found that both the APD and the ATD are independent of sources randomizing in both position and orientation. Therefore the 125I seeds can be considered as point sources, provided that the dose values are scaled down by a factor which accounts for the spatial distribution anisotrophy. Since the computed parameters are only dependent on the implanted activity, the L. L. Anderson method can be applied even if brachytherapy treatments are associated with external beam radiotherapy ("boost"-therapy).     

Characterization and use of a 2D-array of ion chambers for brachytherapy dosimetric quality assurance

The two-dimensional (2D) ionization chamber array MatriXX Evolution is one of the 2D ionization chamber arrays developed by IBA Dosimetry (IBA Dosimetry, Germany) for megavoltage real-time absolute 2D dosimetry and verification of intensity-modulated radiation therapy (IMRT). The purpose of this study was to (1) evaluate the performance of ion chamber array for submegavoltage range brachytherapy beam dose verification and quality assurance (QA) and (2) use the end-to-end dosimetric evaluation that mimics a patient treatment procedure and confirm the primary source strength calibration agrees in both the treatment planning system (TPS) and treatment delivery console computers. The dose linearity and energy dependence of the 2D ion chamber array was studied using kilovoltage X-ray beams (100, 180 and 300 kVp). The detector calibration factor was determined using 300 kVp X-ray beams so that we can use the same calibration factor for dosimetric verification of high-dose-rate (HDR) brachytherapy. The phantom used for this measurement consists of multiple catheters, the IBA MatriXX detector, and water-equivalent slab of RW3 to provide full scattering conditions. The treatment planning system (TPS) (Oncentra brachy version 3.3, Nucletron BV, Veenendaal, the Netherlands) dose distribution was calculated on the computed tomography (CT) scan of this phantom. The measured and TPS calculated distributions were compared in IBA Dosimetry OmniPro-I‘mRT software. The quality of agreement was quantified by the gamma (γ) index (with 3% delta dose and distance criterion of 2 mm) for 9 sets of plans. Using a dedicated phantom capable of receiving 5 brachytherapy intralumenal catheters a QA procedure was developed for end-to-end dosimetric evaluation for routine QA checks. The 2D ion chamber array dose dependence was found to be linear for 100–300 kVp and the detector response (k_user) showed strong energy dependence for 100–300 kVp energy range. For the Ir-192 brachytherapy HDR source, dosimetric evaluation k_user factor determined by photon beam of energy of 300 kVp was used. The maximum mean difference between ion chamber array measured and TPS calculated was 3.7%. Comparisons of dose distribution for different test plans have shown agreement with >94.5% for γ ≤1. Dosimetric QA can be performed with the 2D ion chamber array to confirm primary source strength calibration is properly updated in both the TPS and treatment delivery console computers. The MatriXX Evolution ionization chamber array has been found to be reliable for measurement of both absolute dose and relative dose distributions for the Ir-192 brachytherapy HDR source.     

American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part I: general principles

PurposeTo develop brachytherapy recommendations covering aspects of pretreatment evaluation, treatment, and dosimetric issues for locally advanced cervical cancer.MethodsMembers of the American Brachytherapy Society (ABS) with expertise in cervical cancer brachytherapy formulated updated recommendations for locally advanced (Federation of Gynecology and Obstetrics Stages IB2–IVA) cervical cancer based on literature review and clinical experience.ResultsThe ABS recommends the use of brachytherapy as a component of the definitive treatment of locally advanced cervical carcinoma. Precise applicator placement is necessary to maximize the probability of achieving local control without major side effects. The ABS recommends a cumulative delivered dose of approximately 80–90 Gy for definitive treatment. The dose delivered to point A should be reported for all brachytherapy applications regardless of treatment-planning technique. The ABS also recommends adoption of the Groupe Européen Curiethérapie-European Society of Therapeutic Radiation Oncology (GEC-ESTRO) guidelines for contouring, image-based treatment planning, and dose reporting. Interstitial brachytherapy may be considered for a small proportion of patients whose disease cannot be adequately encompassed by intracavitary application. It should be performed by practitioners with special expertise in these procedures.ConclusionsUpdated ABS recommendations are provided for brachytherapy for locally advanced cervical cancer. Practitioners and cooperative groups are encouraged to use these recommendations to formulate their clinical practices and to adopt dose-reporting policies that are critical for outcome analysis.     

Dosimetric comparison of vaginal vault brachytherapy vs applicator-guided stereotactic body radiotherapy with volumetric modulated arc therapy and helical tomotherapy for endometrium cancer patients

We performed this dosimetric study to compare a nonstandard volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT) techniques with high-dose rate (HDR) brachytherapy (BRT) plan of vaginal vault in patients with postoperative endometrial cancer (EC). Twelve postoperative patients with early stage EC were included in this study. Three plans were performed for each patient; dosimetric and radiobiological comparisons were made using dose-volume histograms and equivalent dose for determining the planning target volume (PTV) coverages in brachytherapy and external beam radiotherapy, and organs-at-risk (OARs) doses between three different delivery techniques. All the plans achieved adequate dose coverage for PTV; however, the VMAT plan yielded better dose conformity, and the HT plan showed better homogeneity for target volume. With respect to the OARs, the bladder D_2cc was significantly lower in the BRT plan than in the VMAT and HT plans, with the highest bladder D_2cc value being observed in the HT plan. However, no difference was observed in the rectum D_2cc of the three plans. Other major advantages of the BRT plan over the VMAT and HT plans were the relatively lower body integral doses and femoral head doses as well as the fact that the integral doses were significantly lower in the BRT plan than in the VMAT and HT plans. This is the first dosimetric comparison of vaginal vault treatment for EC with BRT, VMAT, and HT plans. Our analyses showed the feasibility of stereotactic body radiotherapy technique as an alternative to HDR-BRT for postoperative management of EC patients.     

Artificial intelligence in brachytherapy: a summary of recent developments

Artificial intelligence (AI) applications, in the form of machine learning and deep learning, are being incorporated into practice in various aspects of medicine, including radiation oncology. Ample evidence from recent publications explores its utility and future use in external beam radiotherapy. However, the discussion on its role in brachytherapy is sparse. This article summarizes available current literature and discusses potential uses of AI in brachytherapy, including future directions. AI has been applied for brachytherapy procedures during almost all steps, starting from decision-making till treatment completion. AI use has led to improvement in efficiency and accuracy by reducing the human errors and saving time in certain aspects. Apart from direct use in brachytherapy, AI also contributes to contemporary advancements in radiology and associated sciences that can affect brachytherapy decisions and treatment. There is a renewal of interest in brachytherapy as a technique in recent years, contributed largely by the understanding that contemporary advances such as intensity modulated radiotherapy and stereotactic external beam radiotherapy cannot match the geometric gains and conformality of brachytherapy, and the integrated efforts of international brachytherapy societies to promote brachytherapy training and awareness. Use of AI technologies may consolidate it further by reducing human effort and time. Prospective validation over larger studies and incorporation of AI technologies for a larger patient population would help improve the efficiency and acceptance of brachytherapy. The enthusiasm favoring AI needs to be balanced against the short duration and quantum of experience with AI in limited patient subsets, need for constant learning and re-learning to train the AI algorithms, and the inevitability of humans having to take responsibility for the correctness and safety of treatments.     

Hyperfractionated <Superscript>192</Superscript>Ir Brachytherapy for Recurrent Retroperitoneal Sarcoma: a Technique for Delivery of Local Tumor Boost Dose

BACKGROUND: Radical surgery is the treatment of first choice for retroperitoneal sarcoma. However, locoregional relapse is frequently observed leading to death in the majority of patients. The role of radiotherapy is not well defined in the management of retroperitoneal sarcoma. Yet, there is evidence that adjuvant irradiation does improve local tumor control. MATERIAL AND METHODS: In order to deliver sufficiently high radiation doses to the retroperitoneum, different techniques for application of a local tumor boost dose in addition to external beam treatment have been proposed. We present a technique of hyperfractionated (192)Ir brachytherapy (HFIR) of the tumor bed via intraoperatively implanted plastic catheters. Postoperative CT-based image-guided brachytherapy was performed. In two consecutive patients with recurrent retroperitoneal sarcoma, treatment was delivered twice daily with single doses of 1.5-2.0 Gy in 5-10 mm tissue depth up to a total dose of 18-32.5 Gy. RESULTS: HFIR of the tumor bed was easily accomplished facilitating delivery of high radiation doses to the retroperitoneum. No major late effects of treatment have been observed with a follow-up of 15 and 28 months, respectively. Details of the brachytherapy procedure are presented. CONCLUSION: HFIR via intraoperatively implanted catheters in the retroperitoneum is a technique suitable for application of a local tumor boost dose. Thus, sufficiently high doses of radiation mandatory for long-lasting local tumor control can be delivered in the tumor bed of the retroperitoneum without exceeding normal tissue radiotolerance in this unfavorable disease.     

A Monte Carlo evaluation of the dosimetric characteristics of the EchoSeed Model 6733 (125)I brachytherapy source

PURPOSE: Recently a new design of a (125)I brachytherapy source was introduced for interstitial seed implants, particularly for prostate seed implants. This new source is the EchoSeed Model 6733 (125)I brachytherapy source. Due to the differences in source design and manufacturing process from one new source to the next, their dosimetric parameters should be determined according to the American Association of Physicists in Medicine (AAPM) TG-43 guidelines. METHODS AND MATERIALS: As per AAPM recommendation, it is required to perform at least one experimental study and one Monte Carlo simulation, preferably done by two independent investigators. Other investigators have experimentally determined the dosimetric parameters of this new source. In this project, the Monte Carlo simulated dosimetric parameters of the EchoSeed Model 6733 source have been provided. RESULTS: The results of this evaluation indicate the value of the dose rate constant of 0.97 +/- 3% cGyh(-1)U(-1) in liquid water, which is in good agreement with the measured value of 0.99 +/- 8% cGyh(-1)U(-1) reported by Meigooni et al. The anisotropy constant of the EchoSeed (125)I brachytherapy source was found to be 0.960 in liquid water. CONCLUSIONS: The Monte Carlo Simulated TG-43 dosimetric parameters of the EchoSeed were determined and the results were compared with the published measured data.     

Combined External Beam and Intraluminal Radiotherapy for Irresectable Klatskin Tumors

BACKGROUND: In most cases of proximal cholangiocarcinoma, curative surgery is not possible. Radiotherapy can be used for palliative treatment. We report our experience with combined external beam and intraluminal radiotherapy of advanced Klatskin's tumors. PATIENTS AND METHODS: 30 patients were treated for extrahepatic proximal bile duct cancer. Our schedule consisted of external beam radiotherapy (median dose 30 Gy) and a high-dose-rate brachytherapy boost (median dose 40 Gy) delivered in four of five fractions, which could be applied completely in twelve of our patients. 15 patients in the brachytherapy and nine patients in the non-brachytherapy group received additional low-dose chemotherapy with 5-fluorouracil. RESULTS: The brachytherapy boost dose improved the effect of external beam radiotherapy by increasing survival from a median of 3.9 months in the non-brachytherapy group to 9.1 months in the brachytherapy group. The effect was obvious in patients receiving a brachytherapy dose above 30 Gy, and in those without jaundice at the beginning of radiotherapy (p < 0.05). CONCLUSIONS: The poor prognosis in patients with advanced Klatskin's tumors may be improved by combination therapy, with the role of brachytherapy and chemotherapy still to be defined. Our results suggest that patients without jaundice should be offered brachytherapy, and that a full dose of more than 30 Gy should be applied.