Brachytherapy: Physical and clinical aspects

Brachytherapy is a term used to describe the short distance treatment of cancer with radiation from small, encapsulated radionuclide sources. This type of treatment is given by placing sources directly into or near the volume to be treated. The dose is then delivered continuously, either over a short period of time (temporary implants) or over the lifetime of the source to a complete decay (permanent implants). Most common brachytherapy sources emit photons; however, in a few specialized situations b or neutron emitting sources are used. There are two main types of brachytherapy treatment: 1) Intracavitary, in which the sources are placed in body cavities close to the tumour volume; 2) Interstitial, in which the sources are implanted within the tumour volume. Intracavitary treatments are always temporary, of short duration, while interstitial treatments may be temporary or permanent. Temporary implants are inserted using either manual or remote afterloading procedures. Other, less common forms of brachytherapy treatments include surface plaque, intraluminal, intraoperative and intravascular source applications; for these treatments either g or b emitting sources are used. The physical advantage of brachytherapy treatments compared with external beam radiotherapy is the improved localized delivery of dose to the target volume of interest. The disadvantage is that brachytherapy can only be used in cases in which the tumour is well localized and relatively small. In a typical radiotherapy department about 10-20% of all radiotherapy patients are treated with brachytherapy. Several aspects must be considered when giving brachytherapy treatments. Of importance is the way in which the sources are positioned relative to the volume to be treated, and several different models have been developed over the past decades for this purpose. The advantage of using a well established model is that one benefits from the long experience associated with such models and that one can take advantage of published results. The use of uniform models and methods in brachytherapy treatments simplifies comparison of treatment results. A typical treatment in which a model may be used is, for example, the treatment of cancer of the cervix, in which the dose is given to a specific point A, or low dose rate (LDR) treatments of head and neck cancers using 192Ir wires. In this latter case the Paris model provides suitable guidelines for calculation of the treatment dose and time. For treatments in which dose optimization techniques are used, the treatment times depend on how the sources are positioned relative to the dose calculation points and on the source strength. In situations in which the system to be used is not obvious, the scientific literature should be consulted in order to take full advantage of already existing experience. With the use of a specific method for the brachytherapy treatment and a model for the dose distribution calculation, comparison of results is simplified. The use of a well established dosimetric system for the treatment of cancer gives a common point for such comparisons. However, the use of a model alone is not sufficient to validate results; it is necessary to have a reliable method for determination of the source strength in order for the dose calculation to be accurate. This means that it is necessary for brachytherapy sources to be calibrated, with the calibration traceable to a national or international standards laboratory. The important aspects of any brachytherapy treatment are: Use of a suitable dosimetric model for the treatment time and dose calculation; Use of calibrated sources. These are by no means all the necessary components. A treatment does not reach its goals if the source misses its aimed positions by a large margin; that is, if there are severe geographical misses in placing the sources relative to their intended positions. Owing to the steep dose gradient that characterizes brachytherapy, such geometrical misses may be seriously detrimental to the intended treatment. Thus there is a need for a quality control programme guaranteeing that the treatment is given in accordance with its purposes. From a radiobiological point of view brachytherapy dose delivery can result in complex dose rate effects that may influence the therapeutic outcome. The continuous delivery of dose will influence the repair of sublethal and potentially lethal damage, cell proliferation and other cell kinetics, all of which can modify the radiation response of tumour and normal tissues