International Medical Physics & Biomedical Engineering Workshop 2016 - Aleksander Xhuvani University

Treatment Planning for

Brachytherapy

Alex Rijnders
Europe Hospitals
Brussels, Belgium

[email protected]
 Introduction
Despite large dose gradients:

Inaccurate dose calculation for

an excellent implant procedure
May be as bad as

Accurate dose calculation for

a terrible implant procedure
 Introduction (continued)

We need to improve our dose

calculation technique as we are
developing the implant procedures.

A. Meigooni, AAPM Summer school 2004

 Recommended BT accuracy:

• Physics global accuracy 5-10%

• Input data and algorithm TPS numerical
accuracy of at least ±2%

AAPM TG56, 1997

 “depth dose”, dose as a function of distance for linear Ir-192
sources with the same linear source strength

Ir-192 wire source dose rate

1 - 8 cm 1 muGy/h @ 1 m , per cm

1.2 1 cm

1.0 2 cm
8 cm

3 cm
0.8
doserate (cGy/uur)

4 cm
0.6

5 cm
0.4

6 cm
0.2
1 cm
7 cm
0.0
0 1 2 3 4 5 6 7 8 9 10
8 cm
distance (cm)
 Current most commonly
algorithm:

TG-43

AAPM Task Group 43: Brachytherapy

Dose Calculation Formalism
• Nath et al., Med.Phys. 1995
• Update1: Rivard et al., Med.Phys. 2004
• U1Supplement1: Rivard et al, Med.Phys. 2007
Previously: Sievert Integral

Sievert 1921
Cassell 1982
Williamson 1988
 Simplified to point source water
water

water P
•
  2
distance r
•
 µ en   r0  point source
D water = K ref .  ρ 
.   . ϕ(r)
r
  air

water Ratio of mean mass energy absorption coefficients

  water to air
 µ en 
 ρ  (almost independent of energy, and therefore almost
 
  always equal to ratio of mean mass energy transfer
air
coefficients, except for low energy)
2 Inverse square law term, relative to the distance
 r0 
  at which the reference air kerma is defined (e.g.,
r at 1 cm, or at 100 cm)

φ(r) Correction factor for scatter and attenuation at

distance r from the source, when compared to the same point
in vacuo
Generally based on Meisberger (1968) data
 Sievert limitations
• Does not take into account real scatter behaviour
• μs, μf: mathematical best fit, not physical
quantities

=> Acceptable results for 137Cs and 192Ir, but

errors up to 25% for 125I (AAPM 1995)
How to Calculate Seed Implant Dosimetry?

CT radiograph
 BT Dose Calculation: TG-43
. G(r , θ )
D ( r , θ ) = Sk • Λ • • g (r ) • F (r, θ )
G (r 0, θ 0)
 TG-43 Concept
• Calculate (Monte-Carlo) and measure the dose
distribution around a source => GUIDELINES
• Parameterize TG-43 parameters to fit to the
measurements => CONSENSUS DATASETS

(TG-43 Algorithm)-1

Experimental TG-43 parameters

setup
 TG-43 Concept
• Calculate (Monte-Carlo) and measure the dose
distribution around a source => GUIDELINES
• Parameterize TG-43 parameters to fit to the
measurements => CONSENSUS DATASETS

experimental TG-43 parameters

TG-43 Algorithm
patient
 TG-43 general
Brachytherapy Dosimetry Formalism
• Gx ( r , θ )
D ( r , θ ) = Sk • Λ • • g x (r ) • F (r , θ )
Gx ( r 0 , θ 0 )
.
D(r , θ ) dose rate to water at point P(r,θ)
SK Source Strength,
(numerically = Ref. Air Kerma Rate)
Λ dose rate constant
gx(r) radial dose function
Gx(r,θ) geometry function
F(r,θ) 2-D anisotropy function

Subscript x : L for line source, P for point source approximation

 Dose rate constant
•
D( r 0, θ 0) Ratio of the dose at the reference
Λ= position over the source strength
Sk

= > Converts Air Kerma

to dose at the reference
point
 Geometry function
Deals with inverse square law, eliminating
largest variation in other parameters
1
GP ( r , θ ) = 2 Point source approximation
r
β P( x, y) or P(
GL ( r , θ ) = Line source approximation r,θ)
L•r •sin θ Y
β
1 y
GL ( r , θ ) = 2 Line source, θ = 0° r
r − L2 / 4 θ

X
L
 Radial Dose function
Dose fall-off along the transverse axis of the source
(absorption and scatter effects in water)
• Gx ( r , θ )
D ( r , θ ) = Sk • Λ • • g x (r ) • F (r , θ )
Gx ( r 0 , θ 0 )
r

•
D ( r , θ 0 ) • Gx ( r 0 , θ 0 )
g x (r ) = •
D ( r 0 , θ 0 ) • Gx ( r , θ 0 )
 Anisotropy function
Accounts for anisotropy of the dose distribution around the
source, including absorption and scatter in source and water
• Gx ( r , θ )
D ( r , θ ) = Sk • Λ • • g x (r ) • F (r , θ )
Gx ( r 0 , θ 0 )
r

•
D ( r , θ ) • GL ( r , θ 0 )
F (r ,θ ) = •
D ( r , θ 0 ) • GL ( r , θ )
 Anisotropy function

F (r, θ ) 2D-Anisotropy function

1D-Anisotropy function
Φan(r ) (source orientation unknown)
Anisotropy factor

Anisotropy constant:
φ an Use no longer recommended!
2D-Anisotropy 1D-Anisotropy
function function
 2004: Revised AAPM TG-43
BT Dosimetry Formalism (2-D)
• GL ( r , θ )
D ( r , θ ) = Sk • Λ • • gL ( r ) • F ( r , θ )
GL ( r 0 , θ 0 )
.
D(r , θ ) dose rate to water at point P(r,θ)
SK air kerma strength
Λ dose rate constant
gL(r) radial dose function (line source approximation)
GL(r,θ) geometry function (line source approximation)
F(r,θ) 2-D anisotropy function
Length L
 Revised AAPM TG-43
BT Dosimetry Formalism (1-D) BEST:
• GL ( r , θ )
D ( r , θ ) = Sk • Λ • • gL ( r ) • Φan ( r )
GL ( r 0 , θ 0 )
•
D(r , θ ) dose rate to water at point P(r,θ)
SK air kerma strength
Λ dose rate constant
gL(r) radial dose function (line source approximation)
GL(r,θ) geometry function (line source approximation)
Φan(r) 1-D anisotropy function
 Comparison of 1D formalisms
• 2
r0
BAD D ( r , θ ) = Sk • Λ • 2 • gL ( r ) • Φan ( r )
r
• GL ( r , θ )
BAD D ( r , θ ) = Sk • Λ • • gp ( r ) • Φan ( r )
GL ( r 0 , θ 0 )
• 2
GOOD r0
D ( r , θ ) = Sk • Λ • 2 • gp ( r ) • Φan ( r )
r
• G (r , θ )
L
BEST D ( r , θ ) = Sk • Λ • • g ( r ) • Φan ( r )
L
G (r θ )
L 0, 0
 Data entry in the TPS

TG43 data can be entered either :

• As lookup tables (using linear interpolation)
• As mathematical model fit: polynomial, other

Often data supplied by the TPS manufacturer

In some systems accessible to the user, in
others closed
 Data entry in the TPS
Possible problems linked to this:
• Extrapolation beyond published data (to 0, larger
distances)

• Polynomial fitting might not always give the best

result, attention for behaviour outside the range
used for fitting
 Where to find data?
Preferentially use “consensus” data sets

• Low photon energy sources:

– AAPM TG43U and Supplement
– RPC registry (rpc.mdanderson.org)
– ESTRO website

• High energy sources:

– ESTRO website (+ www.uv.es/braphyqs)
– RPC registry (rpc.mdanderson.org)

• Literature
 Where to find data?
Attention not to mix up data:

As geometry factor interferes in calculated g(r)

and F(r,θ), same geometry function should
be used in TPS

Check final result against the published dose

rate tables
 Source specification
• Reference Air Kerma Rate: to be used in

KR -Calibration certificate
-Dose rate table
-TPS
-Prescription
-Reporting
 Source decay
• In TPS often: Dose = dose rate x time
(mathematically: integration over time)

• For short time implantations (HDR), or long lived

isotopes: dose rate can be considered constant
• In case of afterloaders: decay handling either by
TPS or by Afterloader (or both)
• For manual-LDR (Ir) implants: compensate for
decay during treatment (TPS-manually)
• Permanent implants: integration over time
 Point source
Line source
• For small sources, with no
anisotropy
=> Point source
• Seeds, but orientation not known
=> Line (Point) source, 1D anisotropy
• Short distances from a linear
source
=> Line source, but even then dose on
the source encapsulation ????
 Line source approximation

• Number of point sources

• Number of elementary
line sources
• Line source model of
correct length

=> Only last method can correctly model the anisotropy at

close distance or along the source axis, but even then dose at
surface of source not correctly calculated
 Line source approximation

• Curved sources have to be

decomposed in linear
segments
 Limitations of TG43 algorithm
• Line source
cylindrical source
• Homogeneous “water” patient
• Full scatter patient
• Transit dose (for afterloaders)
• Intersource effect
• Applicators
• Shielding
 Cylindrical source
• Geometry function should be source
(design) dependant
=> Change of TPS structure
• Does not effect accuracy as corrected for in
g(r) and F(r,θ)
Lack of heterogeneity corrections
• High energy sources: nearly the same
behaviour in tissues involved as in water
• Low energy sources: importance of photo-
electric effect increases as energy decreases
I-125 g(r), Variable ρ and Composition
1

water, p=1.00
tissue, p=1.00
tissue, p=1.05
I radial dose function, g(r)
0.1
tissue, p=1.15
tissue, p=1.25
tissue, p=1.50
0.01

0.001
125

0.0001
0 5 10 15 20 25 30
radius [cm]
Lack of heterogeneity corrections
• Historically: no density data available for
BT planning, distance factor considered as
predominant
• With the increased use of CT data:
increasing interest to incorporate
heterogeneity corrections
=> new algorithms (MC)
Lack of heterogeneity corrections
For HDR-PDR: at first glance problem could be
biggest in bronchial implants
But: Prescription done at a fixed distance from the
applicator (1 cm), dose effect correlated with this
prescription system, dose gradient over distance
far more important (palliative treatment).

Prasad 1985: 125I implant in lung: difference of 9 to

20% with dose to water
 Lack of full scatter
• Most TPS assume infinite and full scatter
conditions
• Not true for some interstitial implants, close to the
skin: breast implants, skin, lip,…
• Mangold et al.(2001): skin dose in breast implants
up to 14% overestimated by TPS (TLD)
• Bernard et al. (2005): skin dose in breast implants
up to 20% overestimated by TPS (MC)
• Also shielding creates lack of scatter: 2 to 15%
dose reduction when using shielded vaginal
applicator
 Transit dose
• Source entry,
interdwell movements,
exit
Effect depends on:
• Interdwell velocity
• Source Intensity
• Implant geometry
• Prescribed dose
 Intersource effect
• Depending on number of sources, composition,
geometry

• AAPM 1997: typical prostate implant with large

number of 125I seeds: peripheral dose reduction
up to 6%
• Perez 2003: Tip of tandem of 137Cs Selectron:
reduction more than 20%
 Applicators
• Still often metallic applicators, surrounding the
source cylindrically
• E.g. interstitial needles (breast implant), 192Ir: up
to 1% absorption,
Fletcher type applicator, 137Cs: about 6%
• Could be taken into account during calibration (if
always same kind of applicators is being used),
but needs thorough experimental verification
 Shielding
• Often used in vaginal applicators to protect rectum,
urethra and/or bladder
• Reduction of bladder-rectum dose of 6% to 50%,
depending on material and dimension of shield and
isotope
• Some TPS do not allow corrections, some
implemented 1D correction, others a 2D correction
table (for a 3D problem)
• Warning for OR-dose reporting
 Message
• Be aware off/take into account limitations of your
system/corrections needed

• Whenever changes (improvements) in calculation

algorithms are implemented
=> Discuss the influence of these changes
with the radiation oncologist
Conclusions:
Shortcomings of current algorithm
Tissue heterogeneity corrections generally not available,
nor lack of full scatter correction

Shielding effects not accurately taken into account

Linear Source calculations

TG43 formulation was originally intended for short
brachytherapy sources, few mm in length
Elongated source extensions to TG43 needed (AAPM task
group)
 Shortcomings of current algorithms (2)

Point Source calculations

Point source based distribution calculations are common, particularly
where only the source center location is known but not the 3D
orientation and where orientations are assumed to be randomly
distributed.
1D “anisotropy” corrections simply scale the transverse radial dose
distribution in isotropic (spherical) geometry.
Linear source models provide more accurate anisotropy in single
source dose distributions and for ensembles of implanted sources.
Fixed geometry implants, including ribbons and plaques, lend to linear
source (TG43 “2D” formula) models
 New algorithms

• Monte Carlo –…
• Varian: BrachyVision Acuros
• Nucletron/Elekta : Collapsed Cone

• AAPM TG-186: “Model-based Dose

Calculation in BT: status and clinical
requirements for implementation
beyond TG-43”
 References
• ESTRO Booklet n°8: a practical guide to quality control of brachytherapy
equipment (www.estro.org ; http://www.estro-
education.org/publications/Pages/ESTROPhysicsBooklets.aspx)
• Nath R., Anderson L., Meli J., Olch A.,Stit J., Williamson J ,” Code of practice
for brachytherapy physics: Report of the AAPM Radiation Therapy Commitee
Task Group 56” Med.Phys. 24, 1557-1598 (1997)
• Nath, R., Anderson, L. L., Luxton, G., Weaver, K. A., Williamson, J. F., and
Meigooni, A. S., “Dosimetry of interstitial brachytherapy sources:
Recommendations of the AAPM Radiation Therapy Committee Task Group
No. 43.” Med. Phys. 22, 209-234, 1995.
• Rivard, M. J., Coursey, B.M., DeWerd, L.A., Hanson, W.F., Huq, M.S.,
Ibbott, G.S., Mitch, M.S., Nath, R. and Williamson, J.F. “Update of AAPM
Task Group No. 43 report: A revised AAPM protocol for brachytherapy dose
calculations.” Med. Phys. 31, 633-674, 2004.
• Rivard, M. J., Butler, W.M., DeWerd, L.A., Hanson, W.F., Huq, M.S., Ibbott,
G.S., Melhus, C.S., Mitch, M.S., Nath, R. and Williamson, J.F. ,“Supplement
to the 2004 update of the AAPM Task Group No. 43 Report.” Med. Phys. 34,
2187-2205, 2007.