Practical Handbook of Brachytherapy

Since the last edition of this textbook, interventional radiation therapy (brachytherapy) has undergone significant developments. The incorporation of advanced image-guiding procedures and the establishment of new applicators allow for the highly accurate implantation of complex implants. 3D-guided real-time adaptive brachytherapy is becoming the newest clinical standard. We now find ourselves in an exciting “new era” of brachytherapy. The current edition of this textbook has been updated to include all these new developments in brachytherapy, including the results of recent clinical trials and updates to the brachytherapy guidelines by the European Brachytherapy Group within ESTRO (GEC-ESTRO). A number of highly experienced authors and skilled colleagues from all over Europe have contributed to this edition to educate and inspire all members of the radiation oncology team to utilise the full potential of brachytherapy to the benefit of their patients.

1.Introduction21 2.History of brachytherapy22 3.Physical aspects – sources, dosimetry and dose specification28 3.1.Sources28 3.1.1.Radionuclides in brachytherapy28 3.1.1.1.Gamma and characteristic X-ray radiation28 3.1.1.2.Beta-emitters29 3.1.2.Characterisation of source strength29 3.2.Dosimetry29 3.2.1.Control of reference air kerma rate29 3.2.1.1.Measurement with well-type ionisation chambers29 3.2.1.2.Measurement in compact chambers in solid body phantoms29 3.2.2.Checking the source position30 3.2.3.Calculation of dose distributions30 3.2.3.1.Dose distributions of single sources30 3.2.3.2.Applicator reconstruction31 3.2.4.Optimisation and visualisation of dose distributions33 4.Quality assurance38 4.1.Quality assurance for afterloading devices and procedures in case of emergency for a remote afterloader38 4.2.Quality assurance in brachytherapy treatment planning systems41 4.3.Special methods41 5.Dosimetrical aspects – dose specifications, dose-volume definitions, EQD2 concept46 5.1.Dose specification in general46 5.2.Dose specification in intraluminal and intracavitary therapy47 5.2.1.Source positions along one straight line (e.g. vaginal cylinder, oesophageal/bronchial applicators, vessels)47 5.2.2.Advanced cervical carcinoma48 5.2.3.Endometrial carcinoma not treated surgically48 5.3.Dose specification in interstitial brachytherapy48 5.3.1.Point based systems48 5.3.2.Dose and volume relations, Dose-volume histograms (DVH) and quality parameters (indices)50 5.3.2.1.Relevant dose values and volumes50 5.3.2.2.Quality parameters – QI indices51 5.4.Dose fractionation, combination with external beam and the EQD2 concept53 6.Clinical treatment planning and imaging56 6.1.Clinical treatment planning56 6.1.1.Indication56 6.1.1.1.Definitive treatment56 6.1.1.2.Adjuvant therapy56 6.1.2.Gross Target Volume (GTV) and Clinical Target Volume (CTV)56 6.1.3.Selection of technique, preliminary and definitive treatment plan57 6.1.3.1.Interstitial brachytherapy57 6.1.3.2.Intracavitary brachytherapy60 6.1.3.3.Intraluminal brachytherapy60 6.1.4.Dose, dose fractionation, dose rate60 6.1.5.Infrastructure and personnel planning61 6.2.Modern imaging techniques in brachytherapy62 6.2.1.Basics of image-guided brachytherapy62 6.2.2.Image-guided preliminary treatment planning64 6.2.3.Image-guided application64 6.2.4.Image-guided definitive treatment planning65 6.2.5.Imaging techniques in brachytherapy66 6.2.5.1.CT imaging66 6.2.5.2.MR imaging67 6.2.5.3.US imaging67 7.Instruments and equipment69 7.1.Instruments for interstitial brachytherapy69 7.1.1.Temporary implants69 7.1.1.1.Needles, catheters69 7.1.1.2.Templates71 7.1.1.3.Auxiliary instruments73 7.1.2.Permanent implants74 7.2.Instruments for intracavitary brachytherapy75 7.2.1.Uterovaginal applicators75 7.2.2.Vaginal applicators76 7.2.3.Endometrial applicators77 7.2.4.Intraluminal applicators for tumours in the oesophagus, bronchus, trachea, common bile duct and nasopharynx and for intravascular brachytherapy77 7.2.5.Moulds for cancers of the paranasal sinuses or orbit78 7.3.Surface applicators78 7.3.1.Skin applicators78 7.3.2.Eye applicators79 7.4.Afterloading devices79 7.4.1.The irradiation device80 7.4.2.The control unit81 7.4.3.Important requirements for radiation protection81 8.Intra- and perioperative brachytherapy82 8.1.Introduction82 8.2.Indications and patient selection criteria83 8.2.1.Intraoperative brachytherapy83 8.2.2.Perioperative brachytherapy84 8.3.Practical execution and technique, practical tips85 8.4.Treatment planning87 8.4.1.Target volumes, dose specification and dose, QA87 8.5.Results88 8.6.Side effects89 8.6.1.Short-term toxicity89 8.6.2.Long-term toxicity89 8.7.Summary90 9.Interstitial hyperthermia91 9.1.Techniques of interstitial hyperthermia91 9.2.Planning, performance and documentation of interstitial hyperthermia91 9.3.Quality and effectiveness of hyperthermia92 9.4.Treatment results in interstitial brachytherapy and hyperthermia92 9.4.1.Glioblastoma92 9.4.2.Local and locoregional recurrences of head and neck cancer93 9.4.3.Breast cancer94 9.4.4.Tumours of the small pelvis94 9.4.5.Prostate cancer94 9.6.Summary95 10.Pre- and postoperative supportive care in brachytherapy97 10.1.Patient preparation97 10.2.Anaesthesia and patient positioning97 10.3.Pain management98 10.4.Anti-infective therapy98 10.5.Prophylaxis of thrombosis99 10.6.Pre- and postoperative supportive care by specific tumour sites99 10.6.1.Head and neck cancer99 10.6.2.Breast cancer100 10.6.3.Prostate cancer100 10.6.4.Gynaecological tumours101 10.7.Follow-up102 11.Cervical cancer103 11.1.Indications103 11.2.Brachytherapy pre-planning103 11.2.1.Brachytherapy target volumes103 11.2.2.Organs at risk105 11.2.3.Dose optimisation105 11.2.4.Dose, dose rate, fractionation112 11.3.Technique of applicator insertion112 11.4.Results113 11.4.1.Concomitant chemoradiotherapy113 11.5.Side effects114 11.6.Summary114 12.Endometrial carcinoma117 12.1.Indications, patient selection criteria117 12.1.1.Current Indications for adjuvant radiotherapy, including Brachytherapy117 12.1.1.1.Low risk endometrial cancer117 12.1.1.2.Intermediate risk endometrial cancer117 12.1.1.3.High to intermediate risk endometrial cancer118 12.1.1.4.High risk endometrial cancer118 12.1.1.5.Adjuvant intravaginal brachytherapy119 12.1.2.Brachytherapy in primary endometrial carcinoma119 12.1.3.Intracavitary and interstitial brachytherapy for recurrences119 12.2.Treatment planning120 12.2.1.Target volumes120 12.2.1.1.Adjuvant intracavitary brachytherapy120 12.2.1.2.Primary brachytherapy121 12.2.1.3.Interstitial brachytherapy in recurrent disease122 12.2.2.Dose specification122 12.2.2.1.Adjuvant brachytherapy122 12.2.2.2.Primary brachytherapy123 12.2.2.3.Interstitial brachytherapy123 12.2.3.Dose, dose rate, fractionation123 12.3.Practical execution and technique124 12.3.1.Adjuvant brachytherapy124 12.3.2.Primary brachytherapy124 12.3.3.Interstitial brachytherapy124 12.4.Results125 12.5.Side effects125 12.6.Summary126 13.Primary vaginal carcinoma128 13.1.Indications128 13.2.Brachytherapy pre-planning128 13.2.1.Target volume128 13.2.2.Organs at risk130 13.2.3.Dose planning130 13.2.4.Dose, dose rate and fractionation131 13.2.4.1.Planning aims for the target volumes131 13.2.4.2.Dose constraints for the organs at risk132 13.3.Practical execution and technique132 13.4.Results133 13.5.Side effects133 13.6.Summary134 14.Vulvar carcinoma135 14.1.Indications, patient selection criteria136 14.2.Treatment planning136 14.2.1.Target volumes136 14.2.2.Dose specification137 14.2.3.Dose, dose rate, fractionation138 14.3.Practical execution and technique138 14.4.Results140 14.5.Side effects140 14.6.Summary141 15.Carcinoma of the female urethra142 15.1.Indications, patient selection criteria142 15.2.Treatment planning142 15.2.1.Target volumes142 15.2.2.Dose specification142 15.2.3.Dose, dose rate, fractionation143 15.3.Practical execution and technique143 15.4.Results144 15.5.Side effects144 15.6.Summary145 16.Carcinoma of the prostate146 16.1.Indications, patient selection criteria147 16.1.1.Permanent brachytherapy with J-125 seeds147 16.1.2.Temporary brachytherapy with Ir-192147 16.1.3.Contraindications to brachytherapy147 16.2.Treatment planning147 16.2.1.Target volumes and organs at risk147 16.2.2.Isotope, dose specification and fractionation148 16.2.2.1.Permanent brachytherapy with J-125 , Pd-103148 16.2.2.2.Temporary brachytherapy with Ir-192148 16.3.Practical execution and technique149 16.3.1.Permanent brachytherapy (seeds)150 16.3.2.Temporary brachytherapy151 16.4.Results154 16.4.1.Permanent brachytherapy (seeds)154 16.4.2.Temporary brachytherapy (HDR)154 16.4.3.Salvage brachytherapy as re-irradiation155 16.5.Side effects155 16.5.1.Permanent brachytherapy (seeds)155 16.5.2.Temporary brachytherapy (HDR)155 16.6.Summary156 17.Carcinoma of the penis159 17.1.Indications, patient selection criteria159 17.2.Treatment planning159 17.3.Practical execution and technique159 17.3.1.Surface mould brachytherapy159 17.3.2.Interstitial brachytherapy160 17.4.Results163 17.5.Side effects163 17.5.1.Early side effects163 17.5.2.Late side effects163 17.6.Summary164 18.Bladder cancer165 18.1.Indications165 18.2.Treatment planning165 18.3.Dose specification166 18.4.Dose, dose rate and fractionation167 18.5.Practical execution and technique167 18.6.Results167 18.7.Side effects168 18.8.Summary168 19.Head and neck tumours170 19.1.Carcinoma of the lip170 19.1.1.Indications, patient selection criteria170 19.1.2.Treatment planning170 19.1.2.1.Target volumes170 19.1.2.2.Dose specification170 19.1.2.3.Dose, dose rate, fractionation172 19.1.3.Practical execution, technique172 19.1.4.Results172 19.1.5.Side effects172 19.2.Oral cavity: carcinoma of the floor of the mouth, carcinoma of the mobile tongue172 19.2.1.Indications, patient selection criteria172 19.2.2.Treatment planning174 19.2.2.1.Target volumes174 19.2.2.2.Dose specification175 19.2.2.3.Dose, dose rate, fractionation175 19.2.3.Practical execution, technique175 19.2.4.Results177 19.2.5.Side effects178 19.3.Oropharynx178 19.3.1.Indications, patient selection criteria178 19.3.2.Treatment planning178 19.3.2.1.Target volumes178 19.3.2.2.Dose specification178 19.3.2.3.Dose, dose rate, fractionation178 19.3.3.Practical execution, technique179 19.3.4.Results182 19.3.5.Complications182 19.4.Buccal mucosa182 19.4.1.Indications, patient selection criteria182 19.4.2.Treatment planning182 19.4.2.1.Target volumes182 19.4.2.2.Dose specification182 19.4.2.3.Dose, dose rate, fractionation182 19.4.3.Practical execution and technique183 19.4.4.Results183 19.4.5.Side effects183 19.5.Nasopharynx183 19.5.1.Indications, patient selection criteria183 19.5.2.Treatment planning183 19.5.2.1.Target volumes183 19.5.2.2.Dose specification183 19.5.2.3.Dose, dose rate, fractionation183 19.5.3.Practical execution, technique184 19.5.4.Results184 19.5.5.Side effects186 19.6.Nasal cancer186 19.6.1.Indications, patient selection criteria186 19.6.2.Treatment planning186 19.6.2.1.Target volumes186 19.6.2.2.Dose specification186 19.6.2.3.Dose, dose rate, fractionation186 19.6.3.Practical execution, technique186 19.6.4.Results188 19.6.5.Side effects188 19.7.Summary188 20.Breast cancer191 20.1.Indications, patient selection criteria191 20.1.1.Interstitial brachytherapy as boost191 20.1.2.Partial breast irradiation with interstitial multicatheter brachytherapy alone191 20.1.3.Postoperative surface/interstitial brachytherapy of the chest wall after chest wall recurrence in patients who have previously had radiotherapy193 20.2.Treatment planning193 20.2.1.Target volumes193 20.2.1.1.Interstitial brachytherapy193 20.2.1.2.Target volume in surface brachytherapy199 20.2.1.3.Target volume in interstitial brachytherapy for the chest wall199 20.2.2.Dose specification199 20.2.2.1.Interstitial brachytherapy199 20.2.2.2.Surface brachytherapy200 20.2.2.3.Interstitial brachytherapy chest wall200 20.2.3.Dose, dose rate, fractionation200 20.3.Practical execution and technique201 20.3.1.Interstitial brachytherapy201 20.3.2.Mould (surface brachytherapy)204 20.3.3.Interstitial brachytherapy of the chest wall204 20.4.Results204 20.4.1.Boost204 20.4.2.Interstitial brachytherapy alone205 20.4.3.Surface radiotherapy of the chest wall as re-irradiation205 20.5.Side effects205 20.5.1.Boost206 20.5.2.Interstitial brachytherapy alone as APBI206 20.5.3.Surface salvage-brachytherapy as re-irradiation206 20.6.Summary206 21.Lung cancer210 21.1.Indications, patient selection criteria210 21.1.1.Curative endobronchial brachytherapy210 21.1.2.Palliative endobronchial brachytherapy211 21.1.3.Curative endobronchial brachytherapy combined with external beam radiotherapy211 21.1.4.Palliative endobronchial brachytherapy in combination with external beam radiotherapy211 21.2.Treatment planning212 21.2.1.Target volumes212 21.2.1.1.The target volume for a curative intention212 21.2.1.2.The target volume for a palliative intention212 21.2.2.Dose specification212 21.2.2.1.The dose specification for a curative intention212 21.2.2.2.The dose specification for a palliative intention213 21.2.3.Dose, dose rate, fractionation213 21.3.Practical execution and technique214 21.4.Results215 21.4.1.Results of endobronchial HDR or LDR brachytherapy alone in curative intention215 21.4.2.Results of combined external beam and endobronchial radiotherapy in curative intention215 21.4.3.Results of endobronchial HDR or LDR brachytherapy alone in palliative intention215 21.4.4.Results of combined external beam and endobronchial radiotherapy in palliative intention216 21.5.Side effects216 21.6.Interstitial and intraoperative brachytherapy – indication, technique, results218 21.7.Summary219 22.Oesophageal carcinoma222 22.1.Indications, patient selection222 22.2.Treatment planning222 22.2.1.Target volumes222 22.2.2.Dose specification224 22.2.3.Dose, dose rate, fractionation225 22.3.Practical execution and technique225 22.4.Results226 22.5.Side effects227 22.6.Summary228 23.Carcinoma of the anal canal230 23.1.Indications, patient selection criteria230 23.2.Treatment planning230 23.2.1.Target volumes231 23.2.2.Dose specification231 23.2.3.Dose, dose rate, fractionation231 23.3.Practical execution and technique232 23.4.Results and side effects233 23.5.Side effects234 23.6.Summary235 24.Skin tumours237 24.1.Indications, patient selection criteria237 24.2.Treatment planning237 24.2.1.Target volumes238 24.2.2.Dose specification238 24.2.3.Dose, dose rate, fractionation238 24.3.Practical execution and technique238 24.4.Results241 24.5.Side effects242 24.6.Summary242 25.Uveal choroidal melanomas244 25.1.Indications, patient selection criteria244 25.2.Treatment planning244 25.2.1.Target volumes244 25.2.2.Eye plaques245 25.2.2.1.Ruthenium-106 eye plaques245 25.2.2.2.Iodine-125 eye plaques245 25.2.3.Dose specification and dosimetry246 25.2.3.1.Ruthenium-106 eye plaques246 25.2.3.2.Iodine-125 eye plaques247 25.3.Practical execution and technique247 25.4.Results249 25.5.Side effects251 25.6.Summary251 26.Paediatric malignancies253 26.1.Indications253 26.2.Treatment planning253 26.2.1.Target volumes253 26.2.2.Dose specification253 26.2.3.Dose, dose rate, fractionation253 26.3.Practical execution and technique253 26.4.Results255 26.5.Side effects256 26.6.Summary256 27.Primary and secondary liver malignancies257 27.1.Indication, patient selection criteria257 27.2.Practical execution and technique257 27.3.Treatment planning259 27.4.Results262 27.5.Summary263 28.Soft tissue sarcomas266 28.1.Indications, patient selection criteria266 28.2.Treatment planning266 28.2.1.Target volumes266 28.2.2.Dose specification266 28.2.3.Dose, dose rate, fractionation266 28.3.Practical execution and technique266 28.4.Results267 28.5.Side effects269 28.6.Summary269 29.Keloids and pterygia275 29.1.Indications, patient selection criteria275 29.2.Treatment planning275 29.2.1.Target volumes275 29.2.2.Dose specification275 29.2.3.Dose, dose rate, fractionation275 29.3.Practical execution and technique276 29.4.Results278 29.5.Side effects278 29.6.Summary279 30.Perspectives in brachytherapy281 30.1.Summary283 Index284