Brachytherapy - An International Perspective

Medical Radiology Radiation Oncology
Series Editors: L.W. Brady S.E. Combs J.J. Lu
PaoloMontemaggi
MarkTrombetta
LutherW.Brady Editors
Brachytherapy
An International Perspective
Medical Radiology
Radiation Oncology
Series Editors
Luther W. Brady
Stephanie E. Combs
Jiade J. Lu
Honorary Editors
Hans-Peter Heilmann
Michael Molls
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Paolo Montemaggi Mark Trombetta

Luther W. Brady
Editors
Brachytherapy
An International Perspective
Editors
Paolo Montemaggi
Department of Radiation Oncology
Allegheny General Hospital
Pittsburgh, PA
USA
Luther W. Brady
College of Medicine, Drexel University
Philadelphia, PA
USA
Mark Trombetta
Division of Radiation Oncology
Allegheny Health Network
Cancer Institute
Drexel University College of Medicine
Pittsburgh, PA
USA
ISSN 0942-5373
ISSN 2197-4187 (electronic)
Medical Radiology
ISBN 978-3-319-26789-0
ISBN 978-3-319-26791-3 (eBook)
DOI 10.1007/978-3-319-26791-3
Library of Congress Control Number: 2016936095
Springer International Publishing Switzerland 2016
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My professional life has been inspired by two main figures to

whom I would like to dedicate this work, Professor Attilio
Romanini, my unforgettable mentor and teacher, and Professor
Luther W. Brady, who did not only lead me in my professional
journey but wanted to honor me also by taking part on this
work. Without these two incredible professional figures and
outstanding personalities, I couldnt have done the little things
I did in my professional life. Along with them I am in debt to
the numerous professional figures, students, and residents who
helped me to grow up both as a competent and compassionate
physician. A special thought to my patients, who, through their
courage and suffering taught me the real, essential values of
our human life.
Paolo Montemaggi, MD
To God Almighty and Blessed Mother Mary. To the patients
whom we have the honor and privilege of assisting in their care
and comfort. To our colleagues and trainees with whom
collaboration is an absolute and earnest joy. To my family who
make life wonderful. Robin, my wife, Stephen, David, and a
certain Gunny.
Mark Trombetta, MD
My thanks to all the medical students, residents, faculty, and
colleagues who have contributed to the success of radiation
therapy in the treatment of cancer. Without their help, the
major advances in physics, biology, and clinical treatment
would not have been possible. And to the patience of our
families who encouraged us.
Luther W. Brady, MD
Acknowledgment
Special thank you: Information Technological assistance

Marc Luick, MS
Division of Radiation Oncology, Department of Oncology
Pittsburgh, PA, USA
Special thank you: Executive assistance
Lisa Weiss
Division of Radiation Oncology, Department of Oncology
Pittsburgh, PA, USA
Special thank you: Skin and Sarcoma chapters
Susan King
Botsford Cancer Center
Farmington Hills, MI, USA
vii
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Theodore E. Yaeger IV, Luther W. Brady, Mark Trombetta,
and Paolo Montemaggi
Brachytherapy: A Journey of Hope in the Battle
Against Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Paolo Montemaggi and Patrizia Guerrieri
The Physics of Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Leah K. Schubert and Moyed Miften
13
Physics: Low-Energy Brachytherapy Physics . . . . . . . . . . . . . . . . . .

Jun Yang, Xing Liang, Cynthia Pope, and Zuofeng Li
29
Balloon Brachytherapy Physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dorin A. Todor
41
Part I
Disease Site Specific Topics
Ocular Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stephen Karlovits and Thierry Verstraeten
Head and Neck Brachytherapy: A Description of Methods
and a Summary of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. Jeffrey Demanes
63
71
Breast Brachytherapy: Interstitial Breast Brachytherapy . . . . . . . . 145

Csaba Polgr and Tibor Major
Breast Brachytherapy: Intracavitary Breast Brachytherapy . . . . . . 169
Jaroslaw T. Hepel, David E. Wazer, Frank A. Vicini,
and Douglas W. Arthur
Breast Brachytherapy: Permanent Breast Seed
Implants How and Why?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Jean-Philippe Pignol and Juanita Crook
Breast Brachytherapy: Brachytherapy in the Management
of Ipsilateral Breast Tumor Recurrence . . . . . . . . . . . . . . . . . . . . . . . 197
Mark Trombetta, Thomas B. Julian,
and Jean-Michel Hannoun-Levi
ix
Thoracic Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Paul Renz, Matthew Van Deusen, Rodney J. Landreneau,
and Athanasios Colonias
Image-Guided High-Dose Rate Brachytherapy
in the Treatment of Liver Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Nikolaos Tselis, Konrad Mohnike, and Jens Ricke
Gynecologic Brachytherapy: Endometrial Cancer . . . . . . . . . . . . . . 253
John A. Vargo, Akila N. Viswanathan, Beth A. Erickson,
and Sushil Beriwal
Gynecologic Brachytherapy: Cervical Cancer . . . . . . . . . . . . . . . . . . 269
and Sushil Beriwal
Gynecologic Brachytherapy: Vaginal Cancer . . . . . . . . . . . . . . . . . . 279
and Sushil Beriwal
Gynecologic Brachytherapy: Image Guidance
in Gynecologic Brachytherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Patrizia Guerrieri and Bryan C. Coopey
Prostate: Low Dose Rate Brachytherapy . . . . . . . . . . . . . . . . . . . . . . 299
Pei Shuen Lim and Peter Hoskin
Prostate: High-Dose Rate Brachytherapy in the Treatment
of Clinically Organ-Confined Prostate Cancer . . . . . . . . . . . . . . . . . 319
Nikolaos Tselis, Dimos Baltas, and Nikolaos Zamboglou
Lower Gastrointestinal Brachytherapy: Rectum. . . . . . . . . . . . . . . . 345
Maria Antonietta Gambacorta, Maura Campitelli,
Rezarta Frakulli, Andrea Galuppi, Alessio G. Morganti,
and Vincenzo Valentini
Lower Gastrointestinal Brachytherapy: Anus . . . . . . . . . . . . . . . . . . 353
Stefania Manfrida, Luca Tagliaferri, Rezarta Frakulli,
Maria Antonietta Gambacorta, Alessio G. Morganti,
and Vincenzo Valentini
Brachytherapy of the Skin: Cancers and Other Diseases . . . . . . . . . 365
James Fontanesi, Brian Kopitzki, and Eric Van Limbergen
Soft Tissue Sarcoma Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 389
James Fontanesi, Michael Mott, Jeffrey Margolis,
Gabrielle Monit, and Alain Gerbaulet
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Contents
Contributors
Editors
Paolo Montemaggi Department of Radiation Oncology, Allegheny General
Hospital, Allegheny Health Network, Pittsburgh, PA, USA
Mark Trombetta Professor, Division of Radiation Oncology,
Allegheny Health Network Cancer Institute, Drexel University College of
Medicine, Pittsburgh, PA, USA
Luther W. Brady Radiation Oncology, Drexel University College
of Medicine, Pittsburgh, PA, USA
Contributors
Douglas W. Arthur Department of Radiation Oncology, Virginia
Commonwealth University School of Medicine, Richmond, VA, USA
Dimos Baltas Department of Medical Physics and Engineering,
Sana Klinikum, Offenbach, Germany
Sushil Beriwal Department of Radiation Oncology, University of Pittsburgh,
Pittsburgh, PA, USA
Maura Campitelli Gemelli ART (Advanced Radiation Therapy),
Catholic University of the Sacred Heart, Agostino Gemelli Polyclinic,
Rome, Italy
Athanasios Colonias Department of Radiation Oncology, Allegheny
General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
Bryan C. Coopey Department of Radiation Oncology, Allegheny Health
Network, Pittsburgh, PA, USA
Juanita Crook Department of Radiation Oncology, University of British
Columbia, British Columbia Cancer Agency Centre for the Southern
Interior, Kelowna, BC, Canada
D. Jeffrey Demanes Professor, Department of Radiation Oncology,
Division of Brachytherapy, University of California, Los Angeles, CA, USA
xi
xii
Beth A. Erickson Department of Radiation Oncology, Medical College of

Wisconsin, Milwaukee, WI, USA
James Fontanesi Radiation Oncology, Botsford Cancer Center, Oakland
University/William Beaumont School of Medicine, Farmington Hills, MI,
USA
Rezarta Frakulli Radiation Oncology Center, Department of
Experimental, Diagnostic and Specialty Medicine-DIMES, University of
Bologna, San Orsola-Malpighi Hospital, Bologna, Italy
Andrea Galuppi Radiation Oncology Center, Department of Experimental,
Diagnostic and Specialty Medicine-DIMES, University of Bologna, San
Orsola-Malpighi Hospital, Bologna, Italy
Maria Antonietta Gambacorta Gemelli ART (Advanced Radiation
Therapy), Catholic University of the Sacred Heart, Agostino Gemelli
Polyclinic, Rome, Italy
Alain Gerbaulet Department of Radiotherapy, Institut Gustave-Roussy,
Villejuif, France
Patrizia Guerrieri Department of Radiation Oncology, Allegheny Health
Network, Temple University of College of Medicine, Pittsburgh, PA, USA
Jean-Michel Hannoun-Levi Radiation Therapy Department, Antoine
Lacassagne Cancer Center, Nice, France
Jaroslaw T. Hepel Department of Radiation Oncology, Rhode Island
Hospital, Warren Alpert Medical School of Brown University, Providence,
RI, USA
Peter Hoskin Consultant in Clinical Oncology, Professor, Mount Vernon
Cancer Centre and University College Northwood, London, UK
Thomas B. Julian Department of Surgery, Temple University School of
Medicine, Drexel University College of Medicine, Allegheny Health
Stephen Karlovits Allegheny Health Network Cancer Institute, Allegheny
General Hospital, Pittsburgh, PA, USA
Radiation Oncology, Temple University School of Medicine, Pittsburgh,
PA, USA
Brian Kopitzki Department of Dermatology, Michigan State College of
Osteopathic Medicine, East Lansing, MI, USA
Rodney J. Landreneau Department of Thoracic Surgery, Allegheny
General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
Zuofeng Li Department of Radiation Oncology,
University of Florida College of Medicine, Gainesville, FL, USA
UF Health Proton Therapy Institute, Jacksonville, FL, USA
Contributors
Contributors
xiii
Xing Liang Radiation Physics Solution LLC, Garnet Valley, PA, USA
Pei Shuen Lim Specialist Registrar in Clinical Oncology,
Mount Vernon Cancer Centre, Northwood, UK
Tibor Major Department of Medical Physics, Center of Radiotherapy,
National Institute of Oncology, Budapest, Hungary
Stefania Manfrida Gemelli ART (Advanced Radiation Therapy), Catholic
University of the Sacred Heart, Agostino Gemelli Polyclinic, Rome, Italy
Jeffrey Margolis Department of Oncology, Oakland University, William
Beaumont Medical School, Rochester, MI, USA
Moyed Miften Department of Radiation Oncology, University of Colorado
School of Medicine, Aurora, CO, USA
Konrad Mohnike Department of Radiology and Nuclear Medicine,
Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
Gabrielle Monit Oakland Medical Group, Michigan Healthcare
Professionals, Oakland, MI, USA
Alessio G. Morganti Department of Experimental Oncology Center,
Department of Experimental, Diagnostic and Specialty Medicine-DIMES,
University of Bologna, San Orsola-Malpighi Hospital, Bologna, Italy
Michael Mott Orthopedic Oncology, Henry Ford Hospital,
Detroit, MI, USA
Jean-Philippe Pignol Radiation Oncology Department, Erasmus Medical
Center, Rotterdam, The Netherlands
Csaba Polgr Center of Radiotherapy, National Institute of Oncology,
Budapest, Hungary
Cynthia Pope Department of Radiation Oncology, Beth Israel Deaconess
Hospital, Plymouth, MA, USA
Paul Renz Department of Oncology, Allegheny General Hospital,
Pittsburgh, PA, USA
Jens Ricke Department of Radiology and Nuclear Medicine,
Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
Leah K. Schubert Department of Radiation Oncology,
University of Colorado School of Medicine, Aurora, CO, USA
Luca Tagliaferri Gemelli ART (Advanced Radiation Therapy), Catholic
Dorin A. Todor Department of Radiation Oncology, Virginia
Commonwealth University Health System, Richmond, VA, USA
Nikolaos Tselis Department of Radiation Oncology and Interdisciplinary
Oncology, Sana Klinikum, Offenbach, Germany
xiv
Vincenzo Valentini Gemelli ART (Advanced Radiation Therapy), Catholic

Matthew Van Deusen Department of Thoracic Surgery, Allegheny General
Hospital, Allegheny Health Network, Pittsburgh, PA, USA
Erik Van Limbergen Department of Radiotherapy, University of
Gasthuisberg, Leuven, Belgium
John A. Vargo Department of Radiation Oncology, University of
Pittsburgh, Pittsburgh, PA, USA
Thierry Verstraeten Department of Ophthalmology, Allegheny
Ophthalmic and Orbital Associates, Drexel University College of Medicine,
Pittsburgh, PA, USA
Frank Vicini Department of Radiation Oncology, St. Joseph Mercy
Oakland, Pontiac, MI, USA
Akila N. Viswanathan Department of Radiation Oncology, Brigham and
Womens Hospital and Dana-Farber Cancer Institute, Harvard Medical
School, Boston, MA, USA
David E. Wazer Departments of Radiation Oncology, Tufts Medical
Center, Tufts University School of Medicine, Rhode Island Hospital, Alpert
Medical School of Brown University, Boston, MA, USA
Theodore E. Yaeger IV Professor, Department of Radiation Oncology,
University of North Carolina, Chapel Hill, NC, USA
Jun Yang Professor, Department of Radiation Oncology,
College of Medicine, Drexel University, Philadelphia, PA, USA
Philadelphia Cyberknife Center, Delaware County Memorial Hospital,
Havertown, PA, USA
Nikolaos Zamboglou Department of Radiation Oncology
and Interdisciplinary Oncology, Sana Klinikum, Offenbach, Germany
Contributors
Introduction
Theodore E. Yaeger IV , Luther W. Brady,
Mark Trombetta, and Paolo Montemaggi
The second half of the nineteenth century was a

time for great discovery. People were introduced
to the vacuum cleaner, the light bulb, phonographs, radio, automobiles, and airplanes, among
other things. This new beginning was made ever
more important because it also ushered in a new
era of widespread communication. The new rapid
transfer of information was faster, more efficient,
and more accurate than ever before.
When William Conrad Roentgen, a professor
of physics at Wrzburg University, noted the
newly developed cathode ray tube produced penetrating rays, he presented the finding to the
Wrzburg Society in 1895. For this he shortly
thereafter received the very first Nobel Prize in
T.E. Yaeger IV, MD
Professor, Department of Radiation Oncology,
University of North Carolina, Chapel Hill, NC, USA
L.W. Brady, MD (*)
Radiation Oncology, Drexel University College of
Medicine, Philadelphia, PA, USA
e-mail: [email protected]
M. Trombetta, MD
Professor, Division of Radiation Oncology,
Allegheny Health Network Cancer Institute,
Drexel University College of Medicine,
320 East North Avenue, Pittsburgh, PA, USA
P. Montemaggi, MD
Radiation Oncology (Emeritus), Allegheny Health
Network, Temple University School of Medicine,
Pittsburgh Campus, Pittsburgh, PA, USA
physics in 1901. It was quickly recognized that

very few medical breakthroughs benefitted mankind more than this new X-ray and the new communication capabilities rapidly transmitted the
discovery. It was (and still is) named X because
of the unexplained nature of this form of radiation.
Roentgen noted his crudely cardboard-covered
Crookes tube produced fluorescence from a
nearby tube and quickly recognized it must represent a more distant radiation. He thought it indicated something more penetrating that just
fluorescence. Thus, on November 8, 1895, the new
X-ray was discovered. Soon he noted images of
his hand bones when it was accidentally exposed
onto a barium-plated oxycyanide screen. On
December 22, 1895, he produced the now famous
image of his wifes left hand, wedding ring obviously visible. This became the first intentionally
documented filmed X-ray image. It was immediately reported in Vienna (Die Presse) that the discovery could evaluate bone fractures without the
usual painful manipulation. The good news spread
like wildfire. Historically it is interesting to note
that Professor Goodspeed at the University of
Pennsylvania also reported images of common
streetcar tokens from radiation exposure onto film
but he did not recognize the significance.
Regardless, the news of human images in
Europe quickly spread to America within a few
days. X-ray images were quickly applied to a
variety of medical procedures. Following
Roentgens discovery, clinical and technological

P. Montemaggi et al. (eds.), Brachytherapy: An International Perspective, Medical Radiology,
DOI 10.1007/978-3-319-26791-3_1
skills began to accumulate more rapidly than the

basic knowledge of the biological effects of radiation. However, the toxicities of radiation exposure began to be reported shortly after the
discovery. A British physician, credited with the
first clinical X-ray in England, developed skin
cancer in his hands while experimenting with
X-rays. Thomas Edison noted his assistant
developed hair loss and eventually died from
metastatic skin cancer. In stark contrast, a patient
suffering from advanced breast cancer was
exposed to radiation in 1896 by Emil Grubbe.
She developed an objective and favorable
response. Even given that the treatment technique
was crude and exposure time was long, that
beneficial response was dramatic.
Because of the growing reports of toxicity,
measures were soon adopted to prevent or
minimize undesired radiation exposure but the
popularity of X-ray continued to grow.
Importantly, it was discovered that images of the
whole chest could diagnose tuberculosis. This
was significant as tuberculosis was the leading
cause of death in the last half of the nineteenth
century. Besides the new X-ray, radiation was
detected from a solid uranium source by
Becquerel in 1896. Subsequently Marie and
Pierre Curie showed that the Becquerel radiation
could be accurately measured using ionization
techniques. By December 1898, the Curies were
able to produce reliable radiation from a purified
source of pitchblende and called it radium.
The first known patient to have been treated
with a combination of external beam radiotherapy
and radium was reported at the Memorial SloanKettering Cancer Center for treating a cervix
cancer. At the International Congress of Oncology
in Paris, about 1922, Coutard and Hautant
presented the data in the treatment of advanced
laryngeal cancers. They described a technique
lasting about 7 weeks. This became the standard
by which patients are treated today. Subsequently,
and continuing today, there are vast numbers of
medical reports identifying the positive and
beneficial effects of radiation.
The Curies radium became a standard source
to develop locally applied radiation treatment and
eventually evolved into radium needles and the
T.E. Yaeger et al.
daughter product radon, captured in glass tubes

as a shorter half-life gas for more permanent
placements. Both of these devices were often
inserted directly into tumors. Edith Quimby
demonstrated that a specific pattern of radiation
effects could be reproduced using specific
implant patterns. Other researchers applied
various implant techniques and eventually the
Patterson-Parker system (also known as the
Manchester system) became widely popular and
taught as a standard of care beginning circa 1934.
From a historic point of appreciation, the term
brachytherapy is derived from the Greek word
brachy meaning close and the more common
term therapy for treatment. The utilization of
this technique was suggested to a physician by
Pierre Curie in about 1901 to insert a radium tube
directly into a patients tumor. This was before
the advent of megavoltage radiation which would
eventually become external beam radiotherapy.
So, at least initially, brachytherapy was a
significant and integral part of (mostly) palliative
but occasionally curative management of cancer
patients. It certainly became a standard adjuvant
or primary treatment for many cancers such as
cervix, breast, head and neck, etc., and is
obviously still very much in use today.
It should be noted that both Henri Becquerel
and Madame Curie were awarded the Nobel
Peace Prize for physics in 1903. After WWI, the
Radium Institute was opened in which cancer
specialists came from all over the world and converged to study radiation. In 1930 a major center for brachytherapy was opened in England as
the Holt Radium Institute where Drs. Patterson,
Parker, and Meredith developed a mathematical system of brachytherapy. It was published
as the Manchester System in 1934. While other
radioactive sources were developed (cobalt-60,
cesium-137, iridium-192, etc.), it was not until
about 1953 that an afterloader system using plastic tubes and gold-198 seeds was developed. In
1965, Pierquin and Dutreix determined the rules
of a new system of dosimetry which was named
the Paris System. Intracavitary application to
the cervix and uterine corpus soon followed.
In contemporary practice, many new isotopes
have been added to the brachytherapy
Introduction
armamentarium. Many have been developed to

improve the safety of using radioactive sources as
well as convenience of storage. The original
radium-226 has largely been replaced by cesium,
iridium, iodine, and palladium and some less
commonly used sources. While remote
afterloading is not new, the latest iterations
employ a small-volume (rice grain) highactivity source such as a 10 curie iridium-192
source. Remote afterloading has dramatically
increased the safety of medical personnel by
limiting radiation to the specific patient in a
designated radiation-protected (vault) area. This
has essentially revolutionized brachytherapy,
bringing a revival of the implant treatment
modality. Moreover, advances in computer
calculation technology have fostered the
development of increasingly more sophisticated
treatment planning techniques and low-dose
afterloading has largely been replaced with highdose, short-interval implant delivery. Primarily
iridium-192-based units with highly sophisticated
computer-controlled applicators are most
common. It should be noted there is a unique
application using a high-dose rate balloon with
P-32 for angioplasty to prevent coronary
restenosis after dilatation for revascularization
and locally applied external beam brachytherapy
is developing.
Physicians using various brachytherapy techniques formed the American Radium Society in
1916 intended to allow the exchange of scientific information regarding the utilization of
brachytherapy. This society consisted of cancerinterested physicians from various disciplines
such as gynecology, surgery, radiologists and
now radiation and medical oncologists, and specialist pathologists. The American Radium
Society has fostered multiple specialists to better define brachytherapy indications for applications as modern brachytherapy is still defined as
the technique of placing treatment sources very
close to or within target tumor tissues. Utilizing
the concept of rapid dose degradation with distance (inverse square rule), high tumor doses
can be safely delivered to localized target
regions in a relatively short period of time. This
will use implantation techniques of interstitial,
intracavitary, or topical molds (plaques) either

placed surgically into the tumor or placed clinically depending on the diagnosis and location.
The implant can be placed temporarily as in
intracavitary cervix cancer or permanently as in
a prostate cancer seed implant. Also, there are
various types of source loading techniques/
technologies. They include preloaded, manually
afterloaded, or remotely loaded devices. The
dose rate for the first is typically low and can be
high or low for the mid and the latter is usually
high dose rate. The tumor location typically
determines the implantation technique as
follows:
Intracavitary brachytherapy is commonly
used for the treatment of localized gynecologic,
esophageal, or bronchus malignancies. These
implants are site-specific equipment which are
temporarily left in a patient for a specific period
of time to deliver a prescribed dose.
Interstitial brachytherapy uses sources typically
placed with needles either individual radioactive
seeds or pre-calculated loaded seeds. Older radium
or cesium needles are temporary, but radioactive
seeds are usually permanent using Pd-103 or
I-125. Flexible catheters or ribbons of preloaded
I-125 seeds can be temporarily inserted into
tumors as seen commonly in oral cancers. Surfacedose applications can be custom molds or pre-constructed plaques which can use either low- or
high-dose sources. They are designed to hold the
radioactivity onto a surface to allow uniform dose
distribution to the intended surface area.
Intraluminal brachytherapy consists of a temporary insertion of a single line source, usually
afterloaded using a high dose rate and inserted
into a body lumen to treat the surface and proximal and immediately adjacent tumors. Typically
this is for palliation of a symptomatic obstruction
or bleeding tumor but can be used as part of a
curative attempt as a boost to the primary localized tumor site. Until the 1980s, radioactive
sources were placed directly into the patient,
typically using radium or cesium. Unfortunately
this caused radioactive exposure not only to the
implanting physician but also to assisting
personnel. More recently, remote afterloading
has allowed the surgical placement of devices or
catheters within the safety of a radiation-protected

environment. In the beginning, this concept was
done using fairly crude manipulation of the
loader. More recently and commonly used today,
all loading is automatic and computer controlled
for more precise and accurate delivery. After the
prescribed treatment is completed, all sources are
removed. In this manner, radiation exposure is
only given to the desired patient and to the
intended target tissues.
The evolution of brachytherapy technologies
has progressed consistently. The development of
high-dose, afterloading applicators and concomitant delivery technologies has improved significantly during the last decades. Now there is an
expectation of precise placement with accurate,
reliable delivery and with more appropriate distribution of the desired radiation dose. Beneficially,
these newer devices/techniques maximize brachytherapy effectiveness while also maximizing radiation protection to the treating staff. Although
low-dose brachytherapy is still applicable to specific diagnoses, almost all modern radiation/
brachytherapy treatment programs have the capability for high-dose rate, remote afterloading for
the appropriate circumstances.
It is interesting to note that the evolution from
low-dose rate, high-personnel exposure implant
techniques to the contemporary high dose rate
and limited staff exposure has mostly occurred in
the absence of repeated and verified randomized
controlled clinical trials. However, this paradigm
shift is not wholly inconsistent with many other
major technological breakthroughs that modern
radiotherapy has experienced in recent decades.
These would include advanced, precise, accurate,
T.E. Yaeger et al.
safe, and computer-controlled radiation delivery

techniques and technologies.
The early years of radiation delivery were
fueled by the use of the newly discovered X-ray
and raw radioactive sources in the diagnosis and
crude treatment of cancers. By 1945 nearly
56 million people were given diagnostic X-ray
chest exams as part of a large-scale public health
screening program to diagnose tuberculosis and
to assist in surgical interventions. By 1950 the
number of radiologic exams had more than
doubled to about 15 million per year. Since about
1980 to present, that number has significantly
grown to about 80 or 100 million people receiving
a diagnostic and 260,000 a therapeutic radiologic
procedure with approximately 80,000 patients
undergoing some form of brachytherapy annually.
Apparently, the treatment efficiency and costeffectiveness of modern brachytherapy are
driving resurgence in this approach to treat
cancer. It is now commonplace to see high-dose
rate treatment for breast cancer and high- or lowdose rate therapy for prostate and gynecologic
cancers. Newer on the scene is the budding
technique of low-energy (Kv) electronic
brachytherapy for intraoperative or topical
applications, including treatment of limited skin
cancers.
The intent of this volume is to present contemporary issues in brachytherapy. The authors wish
to explore these possibilities to better define the
concept and application of brachytherapy, to
explore increasing the potential for improved
locoregional tumor control, and to diminish any
risk increases from various programs, as well as
specific therapeutic modalities.
Brachytherapy: A Journey of Hope

in the Battle Against Cancer
Historia Magistra Vitae
Paolo Montemaggi and Patrizia Guerrieri
When Maria Curie discovered natural radioactivity, she probably did not forecast how much that
discovery would impact not only the field of physics but the entire field of medicine. It didnt take
long, however, to see how this newly discovered
energy could affect living cells and tissues. As early
as 1901, we find evidence of radium (226Ra) being
used for treating skin conditions of all types, even
noncancerous such as lupus erythematosus. And
once again, those pioneers did not probably foresee
how much 226Ra and its derivatives would change
the treatment scenario of cancer treatment. What
we know is that as early as 1908 there were already
several publications in the literature and that the
long journey of radium and radioactive elements in
cancer therapy had begun [15]. It has been a fascinating journey, not always easy, but always focused
on the search for a better, safer, and more effective
ways to use this natural energy in the complex and
challenging field of cancer therapy.
This book is aimed to help those who are continuing this journey, allowing them to understand
where they come from and to move their efforts and
research in the right direction, for, as Cicero put it, it
P. Montemaggi, MD (*)
Radiation Oncology (Emeritus), Allegheny Health
Network, Temple University School of Medicine,
P. Guerrieri, MD, MS
Radiation Oncology, Allegheny Health Network,
Temple University School of Medicine,
is in our history, in our past, and in its knowledge

that we may root to build our future, historia magistra vitae: history is the teacher of life.
Brachytherapy is a Greek-derived word composed by two words, brachy, short, and therapy, to
cure. The root indicates the use of radioactivity in
the treatment of cancer by putting the radioactive
sources into a tumor or at short distance from it. In
reality, when its history began, the discipline given
name was Curietherapy, as a way to honor the
work of Maria and Pierre Curie and their contribution to the science of radioactivity. It was only several decades later, when more sophisticated and
effective machines for external beam radiotherapy
became available, that the discipline was renamed
brachytherapy to differentiate it from the teletherapy (Gr: long or distant) that those machines
allowed. Regardless how you want to name it,
brachytherapy has been a main focus in the use of
radiation as a means to battle cancer. It is in this
way that we may view our journey, a continuous
and strenuous effort to find a more efficient and
effective way to use the new energy to fight the
enemy, to ultimately defeat cancer. In this effort
we may individuate some major themes:
The search for dose: the pioneers and the historic systems
The search for strategy: new isotopes, new
systems, new challenges
The search for the target volume: from clinic
to imaging

DOI 10.1007/978-3-319-26791-3_2
P. Montemaggi and P. Guerrieri
Following these themes, we will review our

history up to the present and foresee where we
might go and how to continue to pursue our
target: our unchanged ultimate scope, the defeat
of cancer.
The Search for Dose
The earliest attempts to use the newly discovered

energy as a possible cancer treatment were, one
could say, conducted in tumors arising from easily accessible sites. Among the accessible sites,
gynecologic cancers became almost immediately
the most important field of application and
research. For the early decades of the twentieth
century, gynecologic cancers became the fertile
field for advancing the knowledge and improving
the results that could be obtained through the
clinical use of radioactive sources.
When the pioneers of this new methodology
began their journey, the preminent method of
research was trial and error. The earliest trials
consisted of putting a quantity of radioactive
material in contact with an accessible lesion and
making reference to the time that radioactive
source was left in place. In other words, the reference unit milligram-hours (mg/h) was born, a
reference that remained unchanged for more
than 50 years and that keeps its relevance even
to this modern day as a means of comparison of
previous and new experiences. It might not seem
such a big thing to our now educated eyes, but
it was a great achievement, allowing the comparison of different experiences and results by a
very simple methodology and reference unit [6, 7].
Eventually, however, it became clear that this
exclusively quantitative method of evaluation
was not enough: that further knowledge and
standardization were needed to allow effective
comparison and prediction. It was during the
first and second decades of the twentieth century that several different systems were designed
to allow a rationale planning for the use of
radioactive sources. It is beyond the limit of this
short review to provide a complete description
of those systems, but it is certainly important
that we know those systems and learn from what
they were based on. It is not only important that

we know those systems; it is also highly
educational because, as we will see, the principles on which they were based will remain as
cornerstones in the future evolution of the discipline, leading to different ways of thought that
still permeate the brachytherapy treatment
schedules we use today. In fact, these historic
systems will eventually lead the way to the different radiobiological approaches to dose-time
relationships and low, high, and pulsed dose rate
that presently characterize the discipline. All the
diatribes and discussions we have witnessed
over the last 40 years root back to those historic
systems: to the theoretical principles on which
they were based.
Both in Europe and in the United States, the
efficacy of 226Ra in gynecologic (GYN) cancer
treatment was recognized quite immediately
[5, 8, 9] especially for cervical cancer. By the end
of 1930s, three major centers had already developed systems to properly and effectively plan
how to use radium in the treatment of cervical
cancer. They differ in the shape and material of
applicators as well as, more importantly, in the
quantity and distribution of radioactive sources.
It is also interesting to see, as further endorsement of the continuity referred to earlier, that
the different radiobiological considerations and
hypotheses underlying low and high dose rate,
and continuous and fractionated irradiation, have
taken place and originated from the same cultural
milieu that introduced and applied similar radiobiological concepts, even if in a preliminary form,
in those historic systems for GYN implants:
1. Paris system
2. Manchester system
3. Stockholm system
The main differences between those systems
relate to the application length as a function of
the radioactive load, basically introducing in
clinical practice the fundamentals of what will
become eventually the concept of low and high
dose rate we deal with today.
The concepts on which those three different
systems were based are compared in Table 1.
Brachytherapy: A Journey of Hope in the Battle Against Cancer

Table 1 Comparison of historic dosimetric systems
Paris [10, 11]
Continuous
treatment
(45 days)
Uterine tube
30/35 Ra mg
Two cylindrical
cork vaginal
applicators,
10/15 Ra mg
Stockholm [12]
Three
insertions
every other
week
Two vaginal
silver packers,
up to
60/80 Ra mg
Manchester [13]
Two 72 h
insertions over
total 10 days
time
Three different
uterine loadings:
25, 25, and 20 Ra
mg for different
uterine cavity
lengths
Large, medium,
and small vaginal
ovoid, varying in
loading from
22.5, to 20, to
17.5 Ra mg
The long journey to find the best way to use

the new energy had begun. However, even if
those systems helped planning the implants
and allowed for comparison of results, still the
result was a mere quantitative analysis of the
dose.
The first step toward a more sophisticated
description of dose distribution came from the
Manchester group, through the definition of anatomic reference points [13, 14]. The introduction
of those points for the first time defined the dose
not just in a generic way, but tried to understand
where the dose was being delivered; it defined, at
the same time, the dose needed both to achieve
local control of the disease and to prevent the
occurrence of adverse events as much as possible. Points A and B have constituted a cornerstone of GYN brachytherapy everywhere since
then, allowing for the comparison of results from
different institutions and from different countries. The relevance and significance of those two
points were recognized by ICRU 38 which was
devoted to the standardization of dose in GYN
brachytherapy [15] and still today remain the
yardstick to be used when evaluating a brachytherapy implant [16]. However, modern image
technology has deeply modified our capacity to
see and understand dose distribution, and radiobiology has given us a better way of understanding relationships between dose and fractionation.
Even if Manchester points are not any longer
decisive in implant evaluation, they remain viv-
idly on the scene, a clear sign that no solid progress can be done if it is not rooted in history and
experience.
The definition of points A and B was not the
only relevant contribution of the Manchester
group in the development of brachytherapy. In a
process spanning many years, researchers from
Manchester elaborated a system that allowed for
the rational planning of a brachytherapy implant
according to the surface or volume of the lesion
to be treated. The results of this complex elaboration were made available and easy to use through
a series of tables, known as Paterson-Parker tables
[17]. They were designed with multiple scopes
based on the surface and/or volumes to be treated:
1. To predict the amount of radioactive material
to be used to deliver 1000 mg/h in the surface/
volume
2. To predict the geographic distribution of that
material throughout the surface/volume to
obtain a homogeneous distribution of the
dose and to prevent or reduce to the minimum
the risk for cold or hot spot in the implant,
through specific mathematic rules determining
the relative load at the center and periphery of
the implant
3. To be used with different radioactive sources,
provided the specific activity of the used
isotope is known
The work of the Manchester group provided
a great impetus for further spread and implementation of brachytherapy and maintained its value
and validity to the present day. Brachytherapy
treatment planning systems are still based on the
concepts elaborated from that group, and when
modern imaging techniques allowed for a more
realistic and exact determination of the extent of
the lesion, the validity of those concepts was
proven again.
Another system, similar to that of Manchester,
was elaborated in the United States by Quimby
[18], looking at the same goals but simplifying
the logistic of the radioactive material. While the
Manchester system was based on the availability
of radioactive sources of different activity
requiring a vast range and number of tubes and/or
needles, Quimby proposed the use of sources of

homogeneous activity, yet aiming to maintain
concepts similar to those of Manchester as far as
the geographic distribution of the isotope.
Over the first five decades of the twentieth
century, brachytherapy established its role as the
main stem of radiotherapy in cancer treatment.
It was then that something happened that put a
different perspective in the use of its use in cancer treatment.
Following World War II and the research done
in the field of nuclear physics, a new generation of
machines that allowing more sophisticated external
beam radiotherapy was developed and made available for use in clinical practice. In 1953, 60Co
machines became available and, a few years later,
the in linear accelerators again revolutionized the
rapidly developing field of external beam radiotherapy. The natal technology highlighted new possibilities and advantages, in terms of depth dose,
dose homogeneity, and radiation safety. At the
same time, concerns were growing about the risks
connected to the use of 226Ra, both for patients, in
connection with integral dose and staff safety due
to the high energy and depth penetration of its radiation that required the use of cumbersome and
expensive means of surgical tools and radiation
protection shields. The balance shifted toward a
rapidly declining use of brachytherapy in favor of
external beam treatment. Was the end of brachytherapy nigh? No. New isotopes and new systems
gave renewed impulse to its practice.
The Search for Strategy: New

Isotopes, New Systems, New
Challenges
It was thanks to French researchers that brachytherapy was revived toward the end of the
1950s. The same technological advancements
that made possible the linear accelerator were
used to improve techniques, clinical indications,
and strategies for brachytherapy. The basis of this
new impulse was the design of a new family of
artificially created isotopes for clinical use, based
on a set of differences from the physics and infrastructure requirements typical of 226Ra. New iso-
Table 2 Radium substitute characteristics (ideal)

Characteristic
Energy
226 Ra
High (average
>0.8 Mv)
Half-life
Long
(>1,600 year)
Multi energies
Fixed
No
No
No
Scarce
226 Ra
substitutes
Low to
moderate
(29400 Kv)
Short (days to
months)
Single energy
Variable
Yes
Yes
Yes
Ample
Yes
No
No
Yes
No
Yes
Difficult
Yes
Radiation spectrum
Source dose rate
Flexibility
Malleability
Miniaturization
Clinical
accessibility
Heavy shielding
Afterloading
capability
Remote
afterloading
Staff protection
topes in development should have specific

characteristics devised to ease their application
and safety in clinical use. These new isotopes
were generally referred to as radium substitutes.
Their characteristics in comparison with those of
226
Ra are shown in Table 2.
Several 226Ra substitutes were proposed
(Table 3) and some of them came to be used in
clinical practice for temporary or permanent
implants, but one of those became the cornerstone
of this new era of brachytherapy: 192iridium. Its
success was due not only (nor primarily) to its
own physical characteristics but mainly to the
system expressly designed by French researchers
for its clinical use [19]. This system, which we
may refer to as the new Paris system, made 192Ir
clinical use simple and reliable, allowing for
implant preplanning, image verification, and
result comparison. It is not valid for any other
isotope, which could ordinarily be a limitation,
but its basic concepts can be used more generally
to evaluate and optimize the quality of an implant
in terms of homogeneity.
The availability of these new isotopes had a
great impact on clinical practice of brachytherapy and opened a series of new possibilities and

Table 3 Most used radium substitutes
Element
Radium
Isotope
226
Ra
Energy (MeV)
0.83 (average)
Half-life
1,626 years
Hvl-lead
(mm)
16
Cesium
Iridium
137
0.662
0.397
30 years
73.8 days
3.28
6
Cobalt
Iodine
Palladium
Californium
60
1.25
0.028
0.020
2.4 (average)
neutron
5.26 years
59.5 days
17 days
2.65 years
11
0.025
0.013
192
Cs
Ir
Co
I
103
Pd
252
Cf
125
the development of a new treatment strategy.

Many distinguished physicians and physicists
contributed to the implementation of the new
possibilities using radium substitutes, both in
Europe and in the United States. Names such as
Pierquin, Chassagne, Pernot, and Dutreix in
Europe and others such as Henshcke, Fletcher,
Montague, and Anderson in the United States
remain and will remain in the history of medicine
as eminent researchers who dedicated their entire
life to the battle against cancer. It was not just a
cultural innovation but opened a completely new
world of opportunities for clinical cancer treatment. The last decades of the twentieth century
saw the contemporary development of new drugs,
new imaging techniques, new surgical procedures, and a new family of isotopes, differently
intertwined for a new era of cancer treatment.
The fight still rages, but those new perspectives
opened the way to new opportunities that completely changed the scenario of the battlefield.
These new strategies developed somewhat
differently in Europe and in the United States, but
the goals were the same on both sides of
the Atlantic Ocean: optimizing the use of radioactive sources in cancer treatment strategies,
maximizing clinical results, and minimizing the
negative impact of adverse events. New possibilities emerged in terms of dose-time relationship
and the integration of brachytherapy in a
multidisciplinary approach to cancer treatment.
Temporary and permanent implants and low- and
Clinical application
LDR
intracavitary
interstitial
LDR intracavitary
LDR interstitial,
endoluminal, HDR,
interstitial,
intravascular
HDR intracavitary
Permanent interstitial
Permanent interstitial
High-LET LDR
intracavitary
high-dose rate techniques for which specific

machines were designed and implemented, along
with the development of isotopes specifically
designed to fit the requests and needs of these different strategies, have been the backbone of both
physics and clinical researchers over the last
decades of the twentieth century and the early
part of this century.
During these decades, brachytherapy has
known a great development but has also been
called to face new challenges that emerged from
competitors such as stereotactic radiosurgery,
stereotactic brain and body radiotherapy, and
intensity-modulated radiotherapy which all are
able to simulate, even though not always to
reproduce, dose distributions and clinical results
previously only achievable by a brachytherapy
implant. Furthermore, these new technologies do
not require additional surgical skills and temporal
constraints (as needed with brachytherapy) to
add to the heavy burden of knowledge and
technical ability already existing on the shoulders
of radiation oncologists. All these factors have
challenged the clinical practice of brachytherapy,
progressively tending to limit its use, and, more
importantly, its actual teaching in residency
programs. The new generation of radiation
oncologists sees less and less of brachytherapy
and is more and more focused on the use of
images for treatment optimization through
external beam radiotherapy. But the battle is not
over yet.
10
The Search for Volume:

From Clinic to Imaging
As it has been with the advent of new external

beam radiotherapy machines, also new medical
imagery techniques have determined a series of
challenges and opportunities. Clinicians moved
from the foggy imagery of traditional bidimensional radiology to the exciting realm of virtually
entering the human body to explore and reconstruct in three-dimensional ways the anatomy
and the pathological alterations caused by cancer. The concept of cancer volume has been
completely modified, as it allowed for a more
precise definition of that volume and of its relationship to the adjacent normal structures. This
poses new questions and problems regarding the
distribution of the dose in the volume. New concepts were proposed to adjust dose distribution to
those actual volumes. The contemporary development of more sophisticated and powerful computers made that adjustment possible. All of these
did open the way to a more complex and real
understanding of the different volumes included
in the treated area and to a more detailed description of the dose distribution and dose-effect relationship. Along with new imaging techniques,
biological knowledge about the complex biological reality of cancer allowed for a deeper understanding of the impact that different doses and
different dose-time relationships would have on
the tumor and on the surrounding normal tissues
and structures. Lately, imaging techniques moved
from solely a morphological representation of the
body to describing the functional activity of tissues, organs, and pathological lesions (Table 4).
Nowadays a range of morphological and functional imaging techniques give us precise recon-
struction of the anatomy and the functionality of

normal and pathological structures. This has been
reflected in the definition of different volumes of
interest both in external beam radiotherapy and in
brachytherapy. Several ICRU documents have
addressed this new reality, defining and describing these new reference volumes [15, 16].
As a consequence of these new opportunities
and deeper knowledge of dose-volume and dosetime relationship, external beam radiotherapy has
evolved and has reached a sophisticated level of
capacity to focus the dose to small and well-defined
areas, mimicking the major advantage of brachytherapy. All these new highly focused external beam
radiotherapy techniques have challenged brachytherapists and have promoted a deep reflection to
re-imagine the role of brachytherapy in cancer treatment. The first result of that challenge has been a
similar process of integrating and using modern
images in brachytherapy. Guidelines have been proposed and tested that allow the use, description, and
comparison of brachytherapy treatment to imagedefined volumes [2022]. Modern imaging techniques, both morphological and functional, are now
taken into account in implant planning, dose prescription, and reporting, as well as in evaluating
clinical results both in terms of disease control and
adverse event prevention.
We are certainly far from where we started
more than 100 years ago. Most of the uncertainties and unknowns we faced then have been clarified and solved. On the other hand, brachytherapy
is challenged by highly focused external beam
radiotherapy techniques claiming to guarantee
the same clinical results and the same normal
structure protection against adverse events. Still
there are areas in which brachytherapy remains a
step ahead and in which it maintains a preemi-
Table 4 Volumes of interest and related imaging techniques

Volume
GTV
CTV
BTV
PTV
Definition
Gross tumor volume as defined clinically and by imaging
GTV + margins to define the area in which microscopic
infiltration of the disease is present
Volume that shows a significant variation of biological
activity
Volume that receives the prescribed dose according to beam
or source arrangements
CT
Yes
No
MRI
Yes
No
fMRI PET Image fusion

Yes
No Yes
Yes
Yes Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
nent role and how still important brachytherapy

is in clinical practice.
As we have seen earlier in the text, modern
radiotherapy is moving more and more toward a
sophisticated use of highly focused external beam
radiotherapy techniques and we may be tempted to
forget about brachytherapy. It is complex, requires
skills that are unusual for us, and requires specific
training that is not widely available. It seems easier
just to sit in front of a computer screen drawing
contours and working with physicists and dosimetrists to develop a sophisticated dose plan, all of
which is probably true. However, being easier
doesnt make it always the right choice.
It is necessary that the principles developed
over decades of experience and clinical results of
brachytherapy are not forgotten as useless memories. They still can teach us a lot, and must remain
a solid knowledge basis in our discipline. This is
the purpose of this book. Through a rapid excursion on what brachytherapy has represented in
the development of clinical radiotherapy, we
want to remind all of us that something good may
come from our past and that past lessons must not
be forgotten because historia magistra vitae.
Brachytherapy is a fundamental component of
our history and we cannot neither forget what it
has thought us, nor abandon its path just because
it seems easier. It is our duty to carry on this
teaching and transmit it to the new generations to
build a future solidly rooted in the knowledge and
experience that our history has taught.
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4. Dominici H, Barcat J (1908) Laction therapeutique
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12. Heyman J (1935) The so-called Stockholm method
and the results of treatment of uterine cancer at the
Radiumhemmet. Acta Radiol 16:129148
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in the treatment of cancer of the uterine cervix. Br
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uteri. In: Meredith WJ (ed) Radium dosage: the
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Edinburgh
15. ICRU 38: dose and volume specifications for reporting intracavitary treatment in gynecology (1985)
International Committee for Radiation Units
16. ICRU 58: dose and volume specification for reporting
interstitial brachytherapy (1997) International
Committee for Radiation Units
17. Paterson R, Parker HM (1938) A dosage system for
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18. Quimby EH (1952) Dosage calculations in radium
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20. Viswanathan AN, Beriwal S, De Los Santos J et al
(2012) The American Brachytherapy Society treatment recommendation for locally advanced carcinoma of the cervix Part II: high dose rate
brachytherapy. Brachytherapy 11(1):4752
21. Nag S, Erickson BA, Parich S et al (for the American
Brachytherapy Society) (2000) The American
Brachytherapy Society Recommendations for high
dose rate brachytherapy for carcinoma of the endometrium. Int J Radiat Oncol Biol Phys 48(3):
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22. Viswanathan AN, Erickson BA (2010) Three dimensional imaging in gynecologic brachytherapy: a survey of the American Brachytherapy Society. Int
J Radiat Oncol Biol Phys 76:104109
The Physics ofBrachytherapy

LeahK.Schubert andMoyedMiften
Abstract
Just as the right arm of the radiation oncologist is the medical physicist, so
the heart of brachytherapy is the science of physics. In this chapter we
introduce the basics of brachytherapy physics beginning with the core of
the science and culminating with a comprehensive presentation of the
known science to date.
Introduction
Physics has wide application in brachytherapy.

The radioactive sources used for treatment behave
according to the laws of nuclear physics. By
understanding these principles, one can predict
the behavior of radioactive sources and quantify
the emitted radiation which ultimately deposits
dose into the patient. The development of different sources and constructions has evolved over
time, as have various methods of quantifying
source strength. The dose deposited in a patient
using brachytherapy has unique properties compared with external-beam radiation therapy.
Understanding the principles that govern brachytherapy dose distribution provides a foundation
L.K. Schubert, PhD (*) M. Miften, PhD,

DABR, FAAPM
Department of Radiation Oncology, University of
Colorado School of Medicine, Aurora, CO, USA
e-mail: [email protected]; moyed.
[email protected]
that can be applied to decision making in practice.

Finally, the quantification of brachytherapy dose
distribution has continued to evolve, with most
recent developments innovating the way treatments are planned and dose is calculated.
Basic Classifications
inBrachytherapy
There are various techniques used in brachytherapy, and they can be classified according to different characteristics. In order to gain an overall
perspective of the field of brachytherapy physics,
it is first useful to understand the terminology
used to classify brachytherapy treatment.
2.1
Implant Technique
Brachytherapy is classified according to how

the radioactive sources are placed within the
patient. This is often governed by the anatomical

DOI10.1007/978-3-319-26791-3_3
13
L.K. Schubert and M. Miften
14
treatment site. Interstitial brachytherapy is treatment with sources placed directly in tissue.
Brachytherapy treatments for prostate cancer,
head and neck cancer, soft tissue sarcomas, and
other types of tumors are typically achieved using
an interstitial technique. Intracavitary brachytherapy uses sources that are placed in a body cavity,
which is near or within the tissue to be treated.
Treatments in which radioactive sources are
placed within the vagina or uterus for gynecological disease are classified as intracavitary.
Intraluminal brachytherapy involves the placement of sources within lumen, such as the esophagus or trachea. Surface mold or plaque
brachytherapy uses sources placed on the surface
of the tissue, such as the skin or the globe of the
eye. Finally, the use of radiation sources placed in
blood vessels is classified as intravascular
brachytherapy.
2.2
Treatment Duration
Brachytherapy is classified according to how

long the radiation remains in the patient.
Permanent brachytherapy uses sources that are
permanently placed in the patient, never to be
removed. Temporary brachytherapy uses sources
that are placed for a specified amount of time and
are removed at the completion of treatment.
2.3
Dose Rate
Brachytherapy is classified according to dose rate

or how quickly dose is delivered to the patient.
Low-dose rate (LDR) brachytherapy is defined as
the delivery of dose at rates between 0.4 and
2Gy/h [1]. It may be performed either on an
inpatient or outpatient basis. High-dose rate
(HDR) brachytherapy is defined as the delivery
of dose greater than 12Gy/h [1]. Using modern
HDR delivery equipment, treatment can be
delivered at dose rates as high as 7Gy/min [2].
Due to the short treatment times, HDR treatment
can be performed on an outpatient basis. Mediumdose rate (MDR) brachytherapy delivers dose at
rates between 2 and 12Gy/h [1]. Pulsed dose rate
(PDR) involves short pulses of high-intensity

radiation that are delivered typically once per
hour in order to simulate LDR treatment.
2.4
Source Loading Technique
Brachytherapy is classified according to the

technique in which sources are placed within the
patient. Different source loading techniques will
require variable equipment. Different techniques
will also result in varying levels of source
placement accuracy and resultant radiation
exposure to staff. A vessel is often used to either
allow the clinician to place sources without
directly touching the source (e.g., a Mick
applicator for prostate treatment) or to allow the
source to stay in fixed position within the patient
during treatment (e.g., a tandem and ovoid
applicator for gynecological treatment). That
vessel is called an applicator, and applicators
have specific designs based on treatment site.
Preloaded brachytherapy involves the use of
sources that have been loaded into the applicators
ahead of time. The applicators with the sources
already loaded are then placed into the patient.
During manually afterloaded brachytherapy, the
applicator is first placed in the patient, after
which the clinician manually places sources into
the
applicator.
Remotely
afterloaded
brachytherapy is different, in that the applicator
is first placed in the patient, after which a machine
moves the sources into the applicator while the
clinician is located remotely (often outside of the
room). Remotely afterloaded brachytherapy has
the advantage of reducing radiation exposure to
staff. Because remotely afterloaded treatments
are often carried out using highly technical
equipment, the source placement accuracy is
high. Uniform loading is the use of all sources
either having the same activity or staying within
the patient for the same period of time.
Nonuniform loading is the use of sources either
having different strengths with respect to each
other or staying within the patient for variable
amounts of time. Uniform and nonuniform
loading have different effects on the dose
distribution.
In summary, a single brachytherapy treatment

can be classified into many different groups. For
example, prostate brachytherapy carried out by
implanting into the prostate multiple low-strength
sources using preloaded needles is classified as
interstitial, permanent, LDR, or preloaded
brachytherapy. Gynecological brachytherapy
carried out by placing into the vagina a high-
strength source for a short period of time using a
remote afterloading machine is classified as
intracavitary, temporary, HDR, or remotely
afterloaded brachytherapy. Each classification
can have a different impact on the dose
distribution, radiobiological effects, treatment
delivery accuracy, and staff exposure.
Principles ofRadioactivity
In brachytherapy, the radiation that is used to

treat patients is created by radioactive material.
Radioactivity involves unstable nuclei. The atom
is composed of a nucleus of protons having
positive charge and neutrons having no charge,
surrounded by orbital electrons having negative
charge. The protons within the nucleus are
subject to repulsive electrical forces, while
nuclear forces hold the nucleus together. Different
arrangements of nucleons allow for stable and
unstable states of the nucleus. In an unstable
state, the nucleus transitions to a lower energy
state. This transition results in the release of
energy. This emitted energy is the radiation that
goes on to the deliver dose to brachytherapy
patients.
Radioactivity is the process in which an
unstable nucleus transforms into a more stable
state, releasing energy as radiation in the process.
This transformation to a lower energy state is
termed radioactive decay or disintegration.
Radioactive decay is a stochastic process,
which means that the disintegration of a
nucleus occurs spontaneously. In stochastic
processes, one cannot definitively predict when
a given nucleus will disintegrate. With a macroscopic sample containing numerous atoms,
however, we can quantify the proportion of
nuclei that will decay over a given time period
15
based on probability. It is helpful to understand

the stochastic nature of radioactive decay by
imagining a lottery ball drawing. Many lottery
balls are shaken up in a cage. No one knows
which specific balls will gain enough energy to
jump out of the cage, but we can expect that
there will be a ball exiting the cage at a certain
rate. Likewise, we can expect that for a group
of unstable atoms, a certain proportion of
atoms will undergo radioactive decay and emit
their excess energy, but we cant know for certain exactly which atom will undergo that
transition.
We can predict that the number of atoms disintegrating per unit time (dN/dt) is proportional
to the number of radioactive atoms present (N),
shown in Eq.1. This is also known as the decay
rate. The constant of proportionality () is called
the decay constant. The negative sign in the
equation indicates that the number of radioactive
atoms remaining in a sample decreases with time
because each disintegration corresponds to a
decrease in radioactive nuclei present.
dN
(1)
=- lN
dt

The number of remaining radioactive nuclei as
a group of atoms undergo radioactive decay
can be derived from Eq.1 and is shown by
Eq.2. This equation determines the number of
active nuclei that have not yet decayed. It
changes with time, always decreasing at an
exponential rate.

3.1
N ( t ) = N 0 e- lt
(2)
alf-Life, Mean Life, Effective

H
Half-Life
Another defining characteristic of a radioactive

material is the half-life (T1/2), which is defined as
the time it takes for the number of radioactive
atoms to decay to half of its original number.
Half-life is calculated by Eq.3. This is derived by
solving for time in Eq.2 when N(t) is equal to
one half of N0.
16
T1/ 2 =
ln 2

(3)
After one half-life, the number of radioactive

atoms decreases to half of its original amount.
After two half-lives, the number decreases to half
the original amount and then another half of that
remaining amount, i.e., one-fourth of the original
amount. After n half-lives, the amount of
radioactive material remaining is equal to (1/2)n.
The half-life is a descriptor for how long the
material will stay radioactive or alternatively how
quickly its radioactivity will decay. For example,
Ir-192 has a half-life of 73.83days. This means
that for a given amount of Ir-192, only half of it
will remain radioactive after 73.83days. It is
inversely related to the decay constant as shown
in Eq.3. A long-lived source stays radioactive
for a long period of time, so its half-life is large,
while its decay constant is small (since only a
small proportion of atoms will decay away).
The average life of a radioactive material is a
quantity that describes the average total length of
time a material remains radioactive (Eq.4). The
average life is the time required for all radioactive
atoms to decay, assuming the rate of decay
remains fixed at its initial value. This quantity
can be used when calculating the total dose
received by a patient receiving permanent
brachytherapy, since the radioactive sources will
spend their entire lifetime within that patient.
Tavg = 1.44T1/ 2
(4)

Half-life refers to the lifetime of a material solely
due to its physical properties. It describes the
time it takes to reduce the amount of radioactivity
by the physical radioactive properties of the
material itself. When radioactive material is
injected into a patient, for example, in
radiopharmaceutical procedures, the material
may move through the body, ultimately being
eliminated through physiological processes. In
this situation, there are two processes working
simultaneously to reduce the amount of
radioactivity within the patient. The effective
half-life (Teff) takes into account the radionuclides
physical half-life (T1/2) as well as half-life of the
bodys elimination of the material (Tbiol). The
effective half-life takes these processes into

account and is defined by Eq.5:
3.2
1
1
1
=
+
Teff T1/ 2 Tbiol
(5)

Definition ofActivity
The number of atoms disintegrating per unit time

(Eq.1) is known as the decay rate. The decay rate
of an atom is referred to as the activity of a
radioactive material. Activity is described by
Eq.6:
dN
(6)
= lN
dt

The activity of a material will decrease
exponentially at the same rate as the number of
active nuclei remaining over time. If the activity
is known at a certain time, Eq.7 is used to
calculate the activity at a different time either in
the future or in the past. For example, a patients
treatment plan for an HDR treatment is calculated
using a known source activity on a specific date.
If the patient is treated on a different date, the
source activity will be different than the plan, so
the plan will be adjusted accordingly.
A =-
A ( t ) = A0 e - lt
(7)
The percent of activity change over a certain time

period can be calculation using Eq.7 and is a
useful value to know for clinically used sources.
A simple calculation using this value can identify
the activity of sources after different time periods.
For example, the activity change of I-125 is 1.2%
per day. If I-125 seeds of a certain activity were
planned for prostate seed implantation, but the
case was delayed by 1 day, then the activity of the
seeds would be 1.2% lower on that rescheduled
date. This simple calculation is helpful when
determining source activity values on different
dates. For example, if different dates are used for
sources ordered from seed companies when
activity measurements are performed and when
treatment actually occurs, this calculation is an
easy way to identify the accurate activity on any

given day.
Specific activity is another characteristic of a
radioactive material. It is defined as the activity
per unit mass of radioactive material. The higher
the specific activity, the higher the activity for a
given mass of material. Alternatively, the higher
the specific activity, the smaller the mass of
material for a given amount of activity. High
specific activity sources are ideal for HDR
treatments. They are high in activity in order to
produce enough radiation to deliver high dose
rates. They are also low in mass such that they are
small enough to fit in body cavities for treatment.
Source Strength
Specification
There are multiple methods to define the strength

of a source. Many of these definitions have been
used historically and are now obsolete, while
many are still used interchangeably in various
practices. The definitions of source strength can
be grouped into two main perspectives. The first
perspective quantifies source strength in terms of
amount of material present (standardized as mass
of radium and activity). The second perspective
is from the point of view of the output of emitted
radiation (exposure rate and air-kerma strength).
4.1
Mass ofRadium
The oldest quantity of source strength is the mass

of radium (Ra-226) contained within a source.
Ra-226 was the first radioisotope used for
brachytherapy treatment. Since Ra-226 was the
only source used at the time, it was straightforward
to quantify the amount of radiation emitted. It
was simply related to the physical amount of
radium, or the mass of radium (in units of mg of
radium). In this situation, for a given mass
of radium, the amount and type of emitted radiation and the impact of the source construction
were always consistent. When new sources were
introduced, the mass of those sources did not
produce the same effects as the same mass of
17
radium, since the emitted radiation and source

construction were not the same. Equivalent
masses to Ra-226 were used for the newly
introduced sources. The equivalent mass of
radium is defined as that mass of radium
encapsulated in 0.5mm Pt that produces the same
exposure rate at the calibration distance as the
source of interest. Mass of radium and equivalent
mass of radium, while now considered obsolete
quantities to define source strength, continue to
be used in Cs-137 brachytherapy treatment.
4.2
Activity
Activity is defined as the number of nuclei

undergoing radioactive decay per unit time.
Standard international (SI) units of activity are
becquerel (Bq) [3]. One Bq is equivalent to the
activity of a quantity of radioactive material in
which one nucleus decays per second (1dps).
Another unit of activity is a curie (Ci). Although
Ci is not the SI unit of activity, it is still used in
clinical practice. The typical activity of the Ir-192
source used in HDR is 510Ci. The Ci is related
to the Bq by Eq.8:
1Ci = 3.7 1010 Bq
(8)

Modern sealed radioactive sources are constructed
such that they are encapsulated within a strong
metal lining. This lining will absorb some of the
radiation emitted by the radioactive source
within, thereby diminishing the radiation
reaching the patient. Apparent activity is defined
as the activity of a hypothetic unfiltered point
source that has the same exposure rate at the
calibration distance as the source of interest. It is
considered an obsolete quantity [1, 4] although
still in use for specifying source strength in
permanent brachytherapy treatments.
4.3
Exposure Rate
Exposure rate is a source strength quantity that is

defined in terms of the emitted radiation from the
radioactive material. Exposure rate refers to the
rate at which air is ionized by indirectly ionizing
18
radiation [5]. In the context of brachytherapy,

gamma rays emitted during radioactive decay
ionize the air. Specifically, exposure rate is the
charge rate produced in air by indirectly ionizing
radiation, per unit mass of air (C/kg-h). The SI
unit of exposure rate is C/kg-h, but a commonly
used unit is roentgen per hour (R/h). The two
units are related to each as
1

R
C
= 2.58 104
hr
kg hr
(9)

the energy transferred to air. Sk is defined as the

product of the air-kerma rate, measured at a
specific distance from the source center along the
transverse axis of the source, multiplied by the
square of the measurement distance (Eq.11).
The air-kerma rate measurement is performed in
free air geometry at a large distance from the
source, typically 1m. The units of air-kerma
strength are in U, which is equivalent to
cGy-cm2/h or Gy-m2/h.

The strength of a gamma-emitting radioactive

source is specified in terms of exposure rate
normally at a calibration distance of 1m. The
exposure rate is inversely related to the square of
the distance away from the source. For example,
if one were to move twice as far away from the
source, the exposure rate will decrease by a factor
of four. Therefore, in order to compare quantities
of radiation based on the properties of the sources
themselves, the exposure rate is specified at a
constant, known distance.
Exposure rate at a specific distance ((r)) is
related to activity (A) by the exposure rate
constant () (Eq.10). The exposure rate constant
describes rate at which air is ionized by photons
emitted by radioactive decay. Using the exposure
rate constant, one can calculate the exposure rate
for a given source activity and at a given distance
away from the source. For example, the exposure
rate constant of Ra-226 is 8.25 R-cm2/mg-h. This
means that for 1mg of radium, the exposure rate
is 8.25 R/h at 1cm away.
X ( r )
A
r2
4.5
(11)
Relationships Between
Different Source Strength
Quantities
The various quantities and units used for source

strength can be converted between each other.
Treatment planning programs often allow for
different source strength quantities to be used for
treatment planning. When ordering radioactive
sources from vendors, one can define the source
strength using various quantities. Activity
calibration can also be performed by independent
companies or via in-house measurements, and
different source strength quantities may be used.
In all of these steps, it is critical to know which
quantity is being used and, when differing
quantities are used, how to convert between them.
Source strength quantities have been mistakenly
switched in practice in the past, resulting in dose
errors as high as 30% dose difference [9].
(10)
5
4.4
S k = K ( d ) d 2
adioactive Sources Used

R
inBrachytherapy
Air-Kerma Strength
Air-kerma strength is the quantity endorsed by

the American Association of Physicists in
Medicine (AAPM) to specify source strength for
gamma-emitting brachytherapy sources [4, 68].
Kerma quantifies the energy that is transferred to
charged particles per unit mass in a volume of
medium [5]. Air-kerma strength is a measure of
A variety of radioactive sources have been used

for different brachytherapy procedures. There are
historical, physical, or practical reasons why different sources are used. There are several desirable properties that make an ideal source for
treatment. The first property is the type and energy
of radiation emitted by the source. These impact
the dose delivered to the patient and the radiation
exposure to the staff involved in the procedure.

The energy should be low enough to provide a
desired sharp dose falloff, yet high enough to treat
in depth with acceptable dose heterogeneity.
Higher energy gammas that can penetrate through
the patient will result in higher staff exposure. The
sources specific activity should be an optimal
value to allow for the delivery of desired dose
rates while sufficiently small to be placed within
the body. Finally, the sources half-life should be
optimal to support the working life of the source
such that it can deliver sufficient doses over the
desired treatment duration.
Sources for brachytherapy treatment are
uniquely constructed with various sizes and
shapes. The radioactive portion of the source is
surrounded by an encapsulating material. The
encapsulation prevents radioactive material from
leaking out. The encapsulation also absorbs non-
penetrating radiation emitted from the source,
including low-energy gammas, betas, and alphas,
which would otherwise increase the surface dose
with minimal contribution to the treatment
therapeutic goal. Different sources are constructed
with various thicknesses and types of
encapsulating materials. The construction of the
radioactive material within the encapsulation will
also vary. Some may be in the form of small
pellets or rods all held within the encapsulation.
Table1 summarizes the properties of common
radioactive sources used historically and
currently.
Brachytherapy Dose
Distributions
6.1
haracteristics andClinical
C
Impact
Brachytherapy dose distributions have unique

characteristics compared with external-beam
dose distributions. It is important understand
these characteristics, as they can impact various
practices in brachytherapy.
Brachytherapy dose distributions exhibit a
high dose gradient, which allows for a rapid dose
falloff from the radioactive source. This is due to
19
the low energy of radiation emitted. The energy of

the emitted radiation is in the keV range as
opposed to the MeV range. The main advantage
of this dose gradient is to allow for sparing of
nearby normal tissue. On the other hand, there are
consequences for this high dose gradient. The first
consequence is that the more rapid the dose falloff, the more difficult it can be to provide dose
coverage for targets farther away from the source.
In order to cover tissue that extends farther away
from the source, the tissue closest to the source
will receive a higher dose. Brachytherapy treatments are thus characterized by heterogeneous
dose distributions. For example, in vaginal cylinder treatments, when prescribing to a depth of
0.5cm from the surface of the applicator, the
vaginal mucosa on the surface of the cylinder can
receive a dose up to twice as high as the prescription dose. In order to mitigate hotspots, the largest
possible applicator that can be comfortably fitted
is used. This practice especially applies when
selecting vaginal applicator sizes (particularly
cylinders and ovoids). The reason for this practice
is that dose gradient is sharper closer to the source
than farther away. Therefore, the largest applicator moves the tissue as far away from the source
as possible in order take advantage of the lower
dose gradient. Finally, high-dose heterogeneity is
the reason for pretreatment quality assurance
evaluation in balloon-based brachytherapy. The
balloon integrity must be confirmed prior to delivering every treatment fraction. If the balloon were
to inadvertently deflate during the course of treatment, the tissue surface would move close to the
source and could receive up to ten times higher
dose (Fig.1).
Another consequence of the sharp dose falloff
is the need for delivery of radiation with high
accuracy. The higher the dose gradient, the more
stringent the delivery accuracy need.
Brachytherapy using remote afterloading
technology requires millimeter accuracy of the
source position relative to the applicator position
[4]. While a discrepancy of several millimeters in
positioning may be not a cause for concern in
external-beam radiotherapy (RT), it may be
critical for brachytherapy treatments using
remote afterloading technology.
LDR intracavitary and interstitial,

HDR intracavitary
LDR interstitial
HDR intracavitary, interstitial, and
surface; LDR interstitial
Co-60
Prostate, eye
Prostate
Prostate
Eye
Prostate
Cervix, uterus, sarcoma, head
and neck, prostate, breast
Multiple sites
Cervix, uterus
Common treatment sites

Historically used
Seeds
Seeds,
wires,
ribbons
Seeds
Seeds
Seeds
Applicator
Form
Tubes,
needles
Tubes,
needles
Wire
Gamma
Gamma
Gamma
Beta
Gamma
Gamma
Gamma
Gamma
Clinical
emission
particle
Gamma
28
21
29
224 (max)
412
380
1250
662
0.025
0.008
0.025
N/A
2.5
2.5
11
5.5
59.4days
17days
9.7days
28.8years
2.7days
73.8days
5.26years
30years
Average
particle
HVL (mm
energy (keV) lead)
Half-life
830
12
1600years
1.2% per day

4.0% per day
6.9% per day
2.4% per year
22.6% per day

0.9% per day
12.3% per year
2.3% per year
% activity change
0.04% per year
Abbreviations: HVL half-value layer, HDR high dose rate, LDR low dose rate, keV kilo-electron volt, R roentgen, cm centimeter, mCi millicurie, hr hour, mm millimeter
I-125
Pd-103
Cs-131
Sr-90
LDR interstitial and surface

LDR interstitial
LDR interstitial
HDR surface
LDR intracavitary and interstitial
Cs-137
Au-198
Ir-192
Common clinical applications

LDR intracavitary and interstitial
Isotope
Ra-226
Table 1 Physical properties of radioactive sources commonly used in brachytherapy
20
Fig. 1 Dose distribution for a MammoSite breast

treatment. The 100% line refers to the prescription dose
at 1.0cm depth from the balloon surface. In this figure, the
dose to the balloon surface is twice as high as the
prescription. If the balloon were to completely deflate,
breast tissue could receive dose up to ten times higher
than the prescription dose
6.2
actors That Influence

F
theShape ofBrachytherapy
Dose Distributions
In the simplest scenario, a single radioactive

source, three main factors impact the shape of
brachytherapy dose distributions. The first factor
is distance from the source. For external-beam
RT, the radiation intensity as a function of distance is described by the inverse-square law,
which states that radiation intensity decreases by
the square of the distance from the source. In
brachytherapy, this law is an adequate approximation at large distances from the source. Large
distance generally means a distance that is at
least twice the size of the source [8]. When closer
to the source, however, the inverse-square law
starts to break down.
The second factor is the impact of the source
itself and its encapsulation on the emitted radiation. Emitted radiation is absorbed or scattered as
it exits the source, prior to reaching the surrounding tissue. In reality, sources are constructed with
a finite shape and size. The impact of the source
on the dose distribution depends on the specific
21
Fig. 2 Dose distribution in water for a realistic Ir-192

source, visualized by the gray rectangle. The red, green,
and blue lines show select isodose volumes. The reduction
of dose along the source longitudinal axis is due to an
increase of self-filtration of radiation as it passes through
more source material
source construction, namely, the source and

encapsulation dimensions and material. Typical
sources are cylindrical in shape, so there will be
more attenuation along the longitudinal axis as
opposed to the transverse axis of the source. This
is because the emitted radiation needs to penetrate more material along the longitudinal axis
before reaching the surrounding tissue and is
therefore more attenuated. The resulting dose is
lower along the longitudinal axis of the source as
opposed to the transverse axis (Fig.2).
Finally, the material surrounding the source will
impact the emitted radiation. The surrounding material will cause photons to attenuate as they move
deeper. In addition to attenuation, the surrounding
material will also cause photons to scatter.
Dose Calculation Methods
7.1
Cumulative Dose Calculations
Cumulative dose calculations determine the

total dose delivered over the duration of treatment (t). The dose rate (D(t)) at a particular
22
time (t) is proportional to activity. The dose rate

changes over time because the source activity
changes over time. Therefore, the dose rate is
calculated as

D ( t ) = D 0 e - lt
(12)
where D0 is the dose rate at the start of treatment

and is the source decay constant. The total
delivered dose over a specific period of time is
determined by taking the integral of Eq.12,
which results in Eq.13. Depending on the relationship between the treatment duration and the
source half-life, this equation can be simplified in
the following ways:
D ( t ) = D 0 T1 1.44 (1 - e - lt )
(13)
2

For permanent brachytherapy using short-lived
sources, the treatment duration is much longer
than the source half-life. Dose is delivered over
the lifetime of the source. Therefore, the total
delivered dose is proportional to the average lifetime of the source and is calculated in Eq.14. An
example treatment of this type is LDR prostate
seed implants.

D = D 0 T1 1.44 = D 0 Tavg
2
(14)

For temporary brachytherapy when the treatment duration is very short compared to the
half-life of the source, the source strength, and
therefore the initial dose rate, changes only minimally throughout treatment. The total delivered
dose can be approximated using Eq.15 [2]. An
example treatment of this type is HDR treatments using Ir-192 or LDR treatments using
Cs-137.
D = D 0T
(15)

For brachytherapy in which the treatment
duration is similar to the source half-life
(more than 5% of the half-life), the source
strength changes throughout the treatment.
Thus, the changing dose rate must be taken
into account when calculating the total delivered dose (Eq.13).
7.2
I ntegral andInterpolation
Methods
Dose distributions around linear brachytherapy

sources, such as sources in the form of tube or
needles, were historically calculated using either
an integral method (Sievert integral) or using an
interpolation method [10, 11]. The Sievert
integral method subdivides a linear source into
several equal segments, where each segment is
small enough to be considered a point source. For
a given location with respect to the source,
corrections for distance, oblique filtration,
attenuation and scatter are separately applied and
contributions summed. Interpolation methods
use a set of data points that has been determined
either using experimental methods or theoretical
calculations. Along-and-away tables have been
used for Cs-137 treatments, and tabulated data
are also used in Paterson-Parker [11] and Quimby
systems [12].
7.3
APM TG-43: Modular

A
Formulism
The dose calculation formulism by the AAPM

Task Group 43 (TG-43) is the current standard
dose calculation method [7, 13]. It can be used
for 1D and 2D dose calculations, and it accounts
for differences in the construction of clinically
used sources. Current treatment planning systems
commonly use TG-43 calculations. The
formulism assumes a cylindrically symmetric
source. It is a homogeneous dose calculation,
assuming that all surrounding media is water.
When performing a CT-based plan, the material
of the applicator and surrounding tissue are not
taken into account during dose calculation.
The TG-43 formulism is a modular formulism,
breaking up the various factors that impact the
dose distribution into individual parameters.
Each parameter is specific to individual sources
in clinical use. This approach uses measured
experimental data and Monte Carlo-generated
data for known sources. The values of the
parameters are dependent on the position of the
23
dose calculation point with respect to the source.

The position of the dose calculation point is in
the polar coordinate system, where the position is
described as a radial distance from the source, r,
and an angular position from the sources
longitudinal axis, (Fig.3).
The TG-43 formulism to calculate dose as a
function of position is shown in Eq.16, where Sk
is the source strength (defined as air-kerma
strength), is the dose rate constant, G(r, ) is
the geometry function, g(r) is the radial dose
function, and F(r, ) is the anisotropy function.
The standard reference position (r0, 0), is at a
radial distance of 1cm along the transverse axis
(=90). This form of the equation is a 2D
calculation, which takes into account realistic
line, cylindrically symmetric sources.
G ( r ,q )
D ( r ,q ) = S k
g ( r ) F ( r ,q ) (16)
G ( r0 ,q 0 )

The dose rate constant, , is defined as the dose

rate to water per unit air-kerma strength at the
reference position. Its units are in cGy/U-h.
The geometry function, G(r, ), accounts for
the variation of relative dose due to the spatial
distribution of activity within the source. It does
not account for scatter and attenuation, but rather
provides an effective inverse-square law, which is
based on an approximate model of the distribution
of radioactivity within the source. It is dependent
on both radial distance and angular position and
its units are in cm2. For a point source, the
geometry function is equal to 1/r2. For a
cylindrical line source, the geometry function
takes the following form (Eq.17), where L is the
active source length and is the angle subtended
by the source with respect to the calculation
point:
b
Lr sin q for q 0
G ( r ,q ) =
(17)
2 1
r 2 L
for q = 0

The radial dose function, g(r), is a dimensionless
quantity that accounts for the dose falloff along
Fig. 3Coordinate system describing the position of the

calculation point (P((r, )) with respect to the brachytherapy source. The source is visualized by the rectangle, where
the active length (L) indicates the length of the radioactive
material shown in gray. The source transverse axis is shown
in the vertical direction and the longitudinal axis is in the
horizontal direction. The angle is the angle that the calculation point makes between the longitudinal source axis and
the source center. The angles 1 and 2 are the angles from
each source end, while is the angle subtended by the
source, with respect to the calculation point. The distance
(r) is the radial distance between the calculation point and
the source center
the transverse plane due to scatter and attenuation

in the surrounding material. At the reference distance of r0 the quantity becomes unity. It is
defined along the transverse axis of the source
and therefore is only dependent on the radial
distance.
The anisotropy function, F(r, ), accounts
for the anisotropic shape of the dose distribution around the source due to source self-filtration and oblique transmission through the
source encapsulation. It describes the variation in dose away from the transverse plane
(i.e., when is not equal to 0). When the
angle is equal to the reference angle 0 (i.e.,
along the transverse plane), the quantity F
becomes unity.
24
The line-source calculation given in Eq.17

takes into account the anisotropic shape of
radiation emitted from realistic sources. One can
simplify this equation by assuming the source is
a point, thus ignoring the anisotropic shape of the
emitted radiation and instead assuming an
isotropic distribution. This simplification is
known as a point-source approximation (Eq.18).
Because the dose distribution is isotropic, the
angular position of the dose calculation point is
no longer a variable, and the dose is solely
dependent on radial distance away from the
source. In the point-source approximation, the
anisotropy function, F(r, ) is replaced by the 1D
anisotropy factor, (r). The anisotropy factor is
found by averaging the dose rate at each distance
with respect to the solid angle.
2
r
D ( r ) = S k 0 g ( r ) F ( r )
r

(18)
The point-source approximation ignores realistic

source geometry and its dosimetric impact and is
less accurate. This approximation is an adequate
approximation if either of the following two
conditions apply: (1) if the distance from the
source is greater than twice the source active
length, such that the calculation point is far
enough so that the distribution of radioactivity
does not largely impact the calculated dose, and
(2) if sources are distributed with random
orientations, such that the dose anisotropy effects
are averaged out [8]. LDR prostate treatments
often use point-source approximations because
of the random orientation of the sources placed
within the tissue. Alternatively, HDR treatments
commonly use line-source calculations in order
to determine a more accurate dose distribution;
because the source travels within applicators of
known, rigid geometry, the source orientation in
the patient can be accurately predicted.
7.4
Image-Based Dose Calculation
Traditional brachytherapy planning has been

based on applicators, where optimized dose
distributions were determined from applicator
positions, source loading schema, and standard

rules. Dose is usually prescribed and tracked to a
few defined points. Three-dimensional (3D)
imaging now allows for patient-specific anatomy
to be explicitly taken into account [1319].
Computed tomography [18, 20, 21] and
ultrasound [2225] are primarily used for
anatomy-based planning, with magnetic
resonance imaging [18, 2629] and functional
imaging such as positron emission tomography
[3032] starting to be adopted. Similar to
planning practices for external-beam RT, the
planning target volumes (PTVs) and organs at
risk (OAR) are contoured on the 3D images. The
brachytherapy applicators are defined on the
image to identify the source positions. The source
dwell times (for HDR) or treatment duration or
source activity (for LDR) may then be adjusted in
order to provide an optimal dose distribution for
target coverage and OAR avoidance. Three-
dimensional isodose distributions and dose-
volume histograms (DVHs) are used to evaluate
plan quality. Forward and inverse planning [8,
3338] may be used to achieve the desired dose
distribution.
Image-based brachytherapy planning can use
the standard TG-43 formulism, which is a
homogeneous dose calculation that assumes that
the applicators and patient anatomy are water
density. Model-based algorithms are alternative
dose calculation algorithms which take into
account the surrounding material. These
algorithms either simulate the coupled photon-
electron radiation transport in the material or they
use multiple dimensional scatter integration
techniques to take into account the materials
impact on scatter dose. Three current methods
are collapsed cone convolution-superposition
(CS) [39], grid-based Boltzmann solvers (BSs)
[4043], and Monte Carlo simulations (MCSs)
[4447]. In CS, dose from primary and scatter
radiation is calculated using kernels which map
the spatial energy deposition response of radiation
in a medium. A CS algorithm is being integrated
to the Oncentra brachytherapy treatment
planning system (Elekta, Crawley, UK). BSs use
deterministic approaches to directly solve the
linear Boltzmann transport equation. A BS
algorithm called Acuros is implemented in the

Brachyvision treatment planning system
(Varian Medical Systems, Palo Alto, CA). MC
simulations use stochastic approaches to solve
the linear Boltzmann transport equation using
random sampling. The use of these model-based
algorithms is currently an active area of research
[4850]. The current recommendation from the
AAPM is to perform TG-43 calculations in
parallel with model-based calculations [50].
Summary
Physics has advanced the development of brachytherapy treatment. Different radioactive sources
and source construction designs continue to be
developed for use in various treatment applications. Throughout the history of brachytherapy,
the methods with which to quantify source
strength have evolved as different sources have
been introduced: starting with the mass of radium
to the current standard of air-kerma strength. The
methods of calculation of dose distributions from
brachytherapy treatments have also evolved.
These methods include simple calculations of
total absolute dose delivered, calculations using
tabulated data that take into account the source
size and construction, calculations which separate
the impact of source construction into modular
components, and the most recent developments
using three-dimensional images and sophisticated
radiation transport algorithms. Brachytherapy
physics, while having a long history, continues to
innovate and advance the field.
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Physics: Low-Energy
Brachytherapy Physics
JunYang, XingLiang, CynthiaPope,
andZuofengLi
Abstract
Low-energy brachytherapy has been a standard for more than one century
of clinical cancer application. We present the isotopes used, the characteristics of these elements, and the physics of use.
Introduction
Low-energy brachytherapy sources, with mean

energy 50keV [1, 2], are widely used in the
radiotherapy treatment of several tumors, including the permanent implant treatment of prostate
J. Yang, PhD (*)
Professor , Department Of Radiation Oncology,
College Of Medicine, Drexel University,
Philadelphia, PA 10102, USA
Philadelphia Cyberknife Center, Delaware County
Memorial Hospital, 2010 Westchester Pike,
Havertown, PA 10102, USA
X. Liang, PhD
Radiation Physics Solution LLC,
Garnet Valley, PA, USA
C. Pope, MS
Department of Radiation Oncology, Beth Israel
Deaconess Hospital, Plymouth, MA, USA
Z. Li, DSc, FAAPM
Florida College of Medicine, Gainesville, MA, USA
UF Health Proton Therapy Institute,
Jacksonville, FL, USA
cancer [3] and the plaque treatment of ocular melanoma [4]. Commonly used low-energy brachytherapy sources include a large number of
iodine-125 seed sources of various designs, palladium-103, and cesium-131 sources. Their lower
energies make them clinically attractive, and radiation safety concerns for patients implanted with
these sources can easily be addressed either by
patient tissue attenuation for permanent implants
or with minimal lead shielding for temporary
implants such as the eye plaques. However, dosimetry of these lower-energy sources, due to their
lower mean energies, is highly perturbed by the
source design and construction, in-tissue attenuation and scattering, and tissue inhomogeneity.
Clinical applications of low-energy brachytherapy sources have seen significant increases due to
their successful use in the transrectal ultrasound
(TRUS)-guided permanent implant treatment of
prostate cancer following the reports of pioneers of
this technique [5, 6]. Other clinical applications,
albeit more limited, include treatment of intraocular melanomas [4] and early-stage lung cancer [7].
This chapter discusses currently or historically used low-energy brachytherapy isotopes,

DOI10.1007/978-3-319-26791-3_4
29
J. Yang et al.
30
how seed construction and design can alter

delivered, dose distributions by these sources,
currently recommended dosimetry calculation
formalism for these sources, and current clinical
applications of low-dose brachytherapy.
Isotopes
clinical situations. Unfortunately, other physical

properties are less desirable. Radium produces a
harmful daughter product, radon-222, as well as
helium gas, which leads to a buildup of pressure
inside sealed sources. Eventually the sources
may crack due to the pressure and release the
harmful daughter products.
Cs: -ray, 30 year half-life, 0.662MeV energy
Cesium sources were developed as an alternative
for radium. Cesiums 0.662MeV energy
allows it to penetrate tissue to a similar degree
as radium. Due to the 30-year half-life of
cesium sources, calibration and treatment
times must be adjusted as the sources age.
Eventually the higher-activity sources must be
replaced to keep the treatment times clinically
acceptable. Cesium sources were widely used
in low-dose gynecological implants such as
cylinder, tandem, and ovoid implants. Cs-137
sources are used in low-dose afterloading
devices [10].
137
Radiation therapy for curing disease began as

brachytherapy following the discovery of X-rays
by Rntgen in 1895. The first reported
brachytherapy treatment was performed in 1903
using radium needles [8]. In these early days, not
many sources of radiation were known. In
modern radiotherapy, isotope choice for a
particular therapy includes weighing many
physical properties, such as half-life, type of
radiation, energy, radiation protection concerns,
specific activity (amount of activity per unit
mass), and production cost.
The following radiation sources have been or
are currently being used for brachytherapy [9],
listed in order of active half-life. They are also 60Co: -ray, 5.26year half-life; 1.17MeV and
conveniently grouped into high-energy photon-
1.33MeV
emitting sources, low-energy photon-emitting Cobalt-60 has a high specific activity, which
sources, and beta-emitting sources.
allows for a very small source size. It has been
used as a replacement for radium, but due to
the short half-life, cesium is used more often.
2.1
High-Energy Sources
Cobalts short half-life means more replacement sources will be required. Co-60 is also
226
Ra: -ray, 1,600year half-life, 0.83MeV avg
used as a source for external beam therapy
energy
machines.
Radium was the first source used for radiotherapy/brachytherapy shortly after the discovery 192Ir: -ray, 73.8day half-life, 0.38MeV avg
of radioactivity and the potential of such therenergy
apy to cure cancer. Radium was used by early Iridium-192 was chosen as a source because its
cancer physicians as brachytherapy techniques
0.38 avg MeV energy is less penetrating than
were developed and improved. Because of the
that of cesium or radium but is strong enough
early experience with radium, there is a large
for use in similar interstitial implants. It also
body of clinical experience using radium neehas a high specific activity, so small sources
dles. Successful prescriptions were developed
may still contain a large amount of activity.
using milligrams of radium required for a
Sources may be seeds spaced in a pattern on
desired effect. As new sources were develribbons or wires. Iridium is also used in high-
oped, the activity prescribed was often based
dose afterloading devices.
on the equivalent milligrams of radium.
198
Au: -ray, 2.7day half-life, 0.412MeV energy
The energy emitted by radium, averaging Gold-198 is used in seed form for permanent
0.83MeV, makes it useful in many interstitial
interstitial implants. It has advantages over
Physics: Low-Energy Brachytherapy Physics
radium because of lower energy and short

half-life. Gold seeds became less favored after
the introduction and popularity of I-125.
2.2
Low-Energy Sources
I: X-ray, 59.4day half-life, 0.028MeV avg

energy
Iodine-125 is a low-energy source often used in
small seeds. In more recent years, it is mostly
commonly used in permanent prostate seed
implants. It has also been used in eye plaques
and brain implants. I-125 is a low-energy photon source that has a very steep dose falloff in
tissue. Shielding needs for radiation protection purposes are very minimal. The low
energy also means that the dosimetry of the
source is more complex and strongly dependent on source design.
31
source construction components and in tissue.

The source strength calibration standard and
patient dose calculation formalism must be
appropriately modified to account for these differences, as described in the following sections
of this chapter.
125
Pd: X-ray, 17 day half-life, 0.021MeV avg

energy
Palladium-103 is an alternative to I-125, with a
similar energy but a shorter half-life. The
shorter half-life may be a biological advantage
as the dose is given over a shorter period of
time. Pd-103 is used in permanent prostate
brachytherapy and eye plaques.
103
Cs: -ray, 9.7day half-life, 0.03MeV avg

energy
Cesium-131 is another alternative to I-125, with a
shorter half-life and similar energy.
2.3
Beta Sources
P: -rays, 14.3day half-life, 0.695MeV avg

energy, 1.71MeV max energy
P-32 is a pure beta emitter. It is used in a disk or
plaque form for skin lesions, as well as in a
wire for interventional vascular brachytherapy
for cardiac artery in-stent restenosis.
32
Sr: -rays, 28.9year half-life, 0.196MeV avg

90
Y: -rays, 64.1h half-life 0.933MeV avg
Strontium-90 has a daughter product, yttrium-90,
that is a pure beta emitter. Sr-90 and Y-90 are
used for eye plaques and other cancers where
depth of penetration is an issue. Y-90 has been
used in microspheres for treatment of hepatic
malignancies. Microsphere brachytherapy
uses glass or resin microspheres embedded
with the nuclide [12].
90
131
It should be noted that the isotopes of 137Cs,

Co, 192Ir, and 198Au are considered to be
radium equivalent, in that their energy spectra are dominated by high-energy photons that
are minimally perturbed by source construction and tissue attenuation [11]. This results in
the definition of milligram radium equivalence as a specification of source strength and
the much simplified dose calculation methods
that apply only to this class of high-energy
sources. In contrast, dose distributions of lowenergy sources of 125I, 103Pd, and 131Cs are significantly modified by the attenuation and
scattering of low-energy photons, both in the
60
Seed Design
andConstruction
In the United States, national source strength

calibration standards of low-energy brachytherapy
sources were first established using the Ritz free-
air chamber for model 6702 and 6711 I-125 seeds
[13]. The calibration, however, included effects
of the 4.5keVK-edge characteristic X-rays
produced in the seeds titanium encapsulation,
leading to an exaggerated estimate of the source
strength. Loftus and Kubo etal. analyzed the
dosimetric effect of this overestimate, leading
NIST to develop the wide-angle free-air chamber
(WAFAC) system as the source strength
calibration standard for low-energy brachytherapy
sources [1416]. Multiple analyses have
32
subsequently been published by relevant

American Association of Physicists in Medicine
(AAPM) committees on the impact of this
standard change on the clinical dosimetry of
prostate implants [1719].
In 1995, the AAPM Task Group 43 published
its recommendations on dosimetry of interstitial
brachytherapy sources [20], unveiling the now
well-accepted TG43 dose calculation formalism
for the only seed sources available at the time: the
Nycomed-Amersham 6702 and 6711 I-125 seeds,
the Theragenics TP-200 Pd-103 seed, and the
Ir-192 seeds from Best Medical and Alpha-
Omega. This report was subsequently updated to
correct for inconsistencies in the original report
and to include later AAPM recommendations on
low-energy brachytherapy sources, recommended
dosimetry data sets for newly available I-125 and
Pd-103 seeds, and guidelines for determination
of dosimetric parameters of low-energy brachytherapy sources [21]. This updated TG43U1
report remains, to this day, the standard for clinical dose calculation, as well as reference dosimetry data determination of such sources.
Low-energy brachytherapy seed sources have
traditionally been designed to geometrically conform to the precedent set by the Amersham model
6702 and 6711 I-125 seeds, with external dimensions of 4.5mm in length and 0.8mm in diameter. While no official explanations on these
dimensions may be identified, it is likely that the
diameter is determined by the intention of needle
gauge size to be used for interstitial implants (a
seed of 0.08cm diameter would fit into an 18
gauge implant needle), while the length is dictated by the US Department of Transportation
regulations relevant to special-form radioactive
materials (with lower limit of 0.5cm or 0.2 inches
in length) for packaging and shipping purposes.
Figure 1, from the TG43U1 report [21], shows
the construction diagrams of some I-125 and
Pd-103 sources, illustrating several common construction characteristics of low-energy brachytherapy sources:
1. A titanium capsule that serves as source

encapsulation, typically a thin titanium tube
manufactured through an extrusion process
J. Yang et al.
2. End enclosures in the form of end welds, cups,

or other mechanisms to seal the titanium tubes
after internal components are inserted into the
tube
3. Active source carriers, in the shape of spheres
or cylinders
4. Active source materials containing the radioactive isotope, impregnated in or absorbed
onto the source carriers
An ideal low-energy brachytherapy source
would be expected to have uniform dose distribution around the source, as well as intersource dose
distribution reproducibility.
Source design, construction, and manufacturing
processes can impact dosimetric characteristics:
1. The titanium encapsulation should have uniform thickness. This is usually achievable via
state-of-the-art manufacturing processes.
2. The end enclosure design should be thin and
uniform and have minimal interseed variations. Thicker end enclosures, such as end
welds or cups, may increase the anisotropy of
dose distribution near the ends of the seed
sources, thereby reducing accuracy of point-
source-
based dose calculation for these
sources. Variations in end-weld thicknesses
among seeds cause actual dose distributions to
deviate from calculated ones, especially in
anisotropic aspects (Fig.2). These variations,
although likely clinically insignificant, have
the potential to significantly increase the
uncertainties of calculated source anisotropy
function values, due to uncertainties in the
thickness of the average end-weld thickness
used in the calculations. They also increase
the uncertainties of measured anisotropy function values.
3. The geometry and material compositions of
active source carriers may affect the dosimetric characteristics:
(a) Use of silver as an active source carrier,
with its 25.51keVK-edge X-rays, will
effectively soften the photon energy spectrum of the encapsulated source, as noted
by Daskalov etal. [22]. Dosimetrically,
this results in lower dose rate constants
33
4.6 mm
End weld
4.7 mm
Resin spheres with 125I absorbed to surface
Titanium capsule
0.5 mm dam resin beads

Au-Cu markers
Titanium capsule
0.8 mm
Amersham health model 6702 source
0.8 mm
NASI model MED3631-A/M or MED3633 source
4.6 mm
End weld
Silver rod with
125I
4.6 mm
absorbed to surface
Titanium capsule
Titanium capsule
Radioactive ceramic
Gold marker
0.8 mm
0.8 mm
Bebig model 125.S06 source
Amersham health model 6711 source

5.0 mm
Titanium
outer capsule
Titanium
inner capsule
4.5 mm
Tungsten
marker
Carbon coating
containing 125I
End weld
Silver spheres with
125I
absorbed to surface
Titanium capsule
0.8 mm
0.8 mm
Best model 2301 source
Imagyn model IS-12501 source

4.5 mm
Titanium
end cup
Titanium
capsule
Lead marker
Graphite pellets with Laser weld

100Pd coating
both ends
0.8 mm
Theragenics model 200 source
Fig. 1 Low-energy brachytherapy sources examined in the AAPM TG43U1 report [22]
Fig. 2 A radiograph of
Amersham 6711 seed
sources. Note the interseed
variations of end-weld
thicknesses and silver
source carrier locations
within the encapsulations
(DRC) of silver-based I-125 seed sources

than of those using other source carriers.
For example, the average DRC value of
silver-based I-125 seeds (Amersham 6711
and Imagyn IS-12501) in the TG43U1

report is 0.953cGyh1 U1, while the
average DRC value of the other seeds
(Amersham 6702, Best 2301, NASI
J. Yang et al.
34
MED3631-A/M, and Bebig/Theragenics

I25.S06) is 1.026cGyh1 U1, a difference of 7.6% (see [22]).
(b) Lack of positional reproducibility of

source carriers within the titanium encapsulation can negatively impact accuracy
of measured dose distribution around the
source, in a manner similar to the interseed thickness variations of end enclosures, as shown in Fig.2 for the Amersham
6711 seeds.

(c) Lack of interseed reproducibility of
geometry of source carriers may increase
the anisotropy values for calculated and
measured source dose distribution, similar
to variations in end-weld thicknesses.
Figure 3 shows electron micrographs of
the ends of two silver rods. The different
degrees of beveling shown in the photos
lead to differences in the calculated and
measured source anisotropy function
values.
4. Lack of uniformity of radioactive source

material deposition on the source carriers can
increase calculated and measured source dose
distribution anisotropy (and even radial dose
function). This can also be seen in Fig.3,
where one of the ends of the silver rods had
little if any active source deposited.
In many clinical applications, the dose
distribution uncertainties introduced by source
construction and manufacturing variations are
mostly mitigated by the number of sources used
for patient treatments, as well as the fact that
dosimetric uncertainties due to these variations
are mostly limited to short distances away from
each source, where the magnitude of such
uncertainties is overshadowed by uncertainties in
source position determination. It is therefore
reasonable to state that point-source-based
patient dose calculations may allow adequate
accuracy of prescription dose calculation.
The sensitivity of low-energy source dose distribution to source design and construction also
mandates that manufacturers should take into
consideration potential dosimetry impacts of any
changes in their source designs and manufactur-
ing processes. Even more importantly, any such

changes should be communicated in a timely
manner to the users, such that potential changes
in the sources TG43 parameters may be identified. Chen etal. performed spectrometric and
phantom measurements of DRC of the model
CS-1 Cs-131 sources before and after production
revisions and found the DRC changed by
0.7%0.5% due to a significant decrease of
fluorescent X-rays produced by the niobium used
as the new source carrier [23].
Newer designs of low-energy brachytherapy
sources continue to be developed. Frank etal.
reported on their development and dosimetric
evaluation of an MRI marker for prostate brachytherapy [24]. By placing cobalt chloride complex
contrast agent markers adjacent to an I-125 seed,
they were able to verify the improved visibility of
the I-125 seeds on MR images. Phantom measurements of such modified seeds confirmed that
the presence of markers does not alter the original
sources anisotropy function values. Gautam etal.
reported on their dosimetric analysis of an I-125
seed modified for thermotherapy by replacing the
original tungsten source carrier with a ferromagnetic alloy material [25]. An 8% change of the
DRC of the source was determined by Monte
Carlo calculations, while only small relative dose
distribution parameters were identified. Rivard
etal. calculated the TG43 parameters using the
Monte Carlo method for a new Pd-103 source
design, with the source available in lengths from
1.0cm up to 6.0cm, at 1.0cm steps [26]. They
found minimal variations of the normalized
source strength as a function of source lengths.
The dose rate constants, however, showed significant dependence on active source lengths, with
percent reductions ranging between 18 and 8% as
active source length increases.
Dosimetry
Low-energy radionuclide sources in clinical

use have different strengths, which historically
have been described as apparent activity. This
quantity was usually derived from exposure
rate at a distance, which is a calibrated quantity
35
Fig. 3 Variations of active source deposition on source carriers. Note that the ends of the silver rods have different
amounts of beveling and of active source depositions due to manufacturing deviations
directly traceable to National Institute of

Standards and Technology (NIST) laboratories
or American Association of Physicists in
Medicine (AAPM) accredited dosimetry calibration laboratories (ADCL). Two-dimensional
dose distribution was calculated based on these
quantities. Currently, air kerma strength (SK) is
the standard brachytherapy source strength
quantity, which can be converted to exposure
rate ( X ) at 1m as

2
S K = X ( Rh -1 ) ( 0.876 cGy / R )(1m ) , (1)

where X is exposure rate measure in Rh -1 . Air

kerma strength is defined as the product of air
kerma rate due to photons of energy ( K ) greater
than a cutoff energy () at a distance (d) and the

square of the distance:

S K = K ( d ) d 2 .
(2)
The cutoff energy, , is 5keV for low-energy

brachytherapy sources according to the update of
AAPM Task Group No. 43 [21].
The air kerma strength of a clinical source
should be calibrated by direct comparison with a
NIST- or ADCL-calibrated source of the same
kind. At NIST, air kerma strength of a source is
calibrated by the wide-angle free-air chamber
(WAFAC) with a precision of 0.01 Gy m 2 h -1 .
An aluminum filter in the WAFAC is used to
exclude low-energy contamination photons,
J. Yang et al.
36
which reflects the cutoff energy in the air kerma

strength definition, to minimize the measurement
uncertainty.
Using the calibrated air kerma strength, the
2D dose rate can be calculated as
G ( r ,q )
g ( r ) F ( r ,q ) ,
D ( r ,q ) = S K
G ( r0 ,q 0 )
(3)

where is the dose rate constant (DRC), G(r,)

is the geometry function, g(r) is the radial dose
function, and F(r,) is the 2D anisotropy
function. The DRC is the ratio of dose rate at the
reference point in water and air kerma strength.
This quantity reflects the fundamental difference
between the current dose calculation and the
traditional. The calculation is done in water/
water equivalence, which makes it more proper
for dosing in patients. The geometry function
reflects inverse square law falloff based on the
source geometry. For instance, the geometry
function for point source is Gp ( r ,q ) = r -2 .
Falloff due to scattering and attenuation is not
part of the geometry function; rather, these
factors are incorporated in the radial dose
function, which is given in a lookup table in the
update of AAPM Task Group No. 43 [21] and its
supplement [27]. Since most of the sources are in
linear form, the 2-D anisotropy function describes
the dose variation as a polar angle relative to the
transverse plane. For point sources, the dose distribution can be written in one dimension as
2
r
D ( r ) = S K 0 g P ( r ) fan ( r ) , (4)
r

where an(r) is the anisotropy factor. Similarly

for linear sources, the dose distribution can be
written as
G ( r ,0 )
g L ( r ) fan ( r ) . (5)
D ( r ) = S K L
GL ( r0 ,0 )

Consensus data sets of dose calculation quantities

are given by the update of the AAPM Task Group
No. 43 [21] and its supplement [27] for clinical
implementation of low-energy I-125 and Pd-103
source models by different manufacturers. These
data sets were derived from published Monte

Carlo simulations or experimentally derived
parameters. Consensus data sets of most low-
energy brachytherapy sources available on the
market as of 2005 can be found in the reports.
Once the dose rate at the time of the procedure
is known, dose rate after a certain amount of time
t can be written as

D ( t ) = D ( 0 ) e
0.693t
T1/ 2
(6)
where T1/2 is the half-life of the isotope and D ( 0 )

is the initial dose rate. The cumulated dose at this
time then can be written as
0.693t
D ( t ) = D ( 0 )(1.44T1/ 2 ) 1 - e T1/ 2
(7)
Total dose after complete decay becomes

Dtotal = 1.44 D ( 0 ) T1/ 2 .
(8)
Below an example of treatment planning for

prostate implant is introduced as an example of
low-energy brachytherapy dosimetry implementation. Intraoperative planning is a popular option
currently for prostate implants, in which TRUS
images are acquired in the operating room and
transferred to the treatment planning system.
Target volume, rectum, and urethra are contoured
on TRUS images, from which a treatment plan is
generated. Point source assumption is usually
used for the treatment planning algorithm. Linear
source models may be used, given the assumption
that sources are parallel to the needle. However,
this assumption may cause calculation inaccuracies. On the other hand, source orientation may be
more accurately determined on CT images during
post-implant dose evaluation by using more
advanced automatic segmentation methods. Dose
distribution can then be calculated as a sum of the
dose from each seed.
4.1
Example
Amersham 6702 I-125 seeds are used for a

prostate implant case. The air kerma strength is
0.5 U.One seed is 3cm from the anterior rectal

wall. What is the dose rate from this seed to the
closest point on the rectum? How much dose will
this point get from this source after 1 month?
After complete decay?
We explore these questions based on the point
source model. The dosimetric quantities can be
found in the update of AAPM Task Group No. 43
[21] as
S k = 0.5 U; = 1.036 cGy h 1 U 1 ;
g P ( r ) = 0.702; fan ( r ) = 0.951;
T1/ 2 12 = 59.4 days = 1425.6 h.

Therefore, the dose rate at the point is
2
r
D ( r ) = S K 0 g P ( r ) fan ( r )
r
2
1
= 0.5 1.036 0.702 0.951
3
= 0.0384 cGy h 1 .

After 1 month, the cumulated dose at this point is

0.693t
D ( t ) = D ( 0 )(1.44T1/ 2 ) 1 e T1/ 2
30
0.693
59.4
= 0.0384 1.44 1425.6 1 e
= 23.28 cGy.

The total dose is
D = 1.44 D ( 0 ) T
total
1/ 2
chapter are below 50keV, with effective energies

similar to low-energy X-rays between 30 and
150keV.Specifically, with reference to Co-60,
I-125, the most commonly used low-energy
brachytherapy source, has an RBE in the range of
1.12.0. Pd-103 has a lower energy and slightly
larger LET compared with iodine-125, and its
RBE values are generally accepted to be about
10% higher [2932].
The RBE also depends on the prescription
dose and the dose rate. The dose and dose rate
will be determined primarily by the nature and
duration of implant. Temporary implants deliver
a typical dose of 6090Gy in a few days, with a
dose rate ranging from 0.5 to 0.8Gyh1 using
high-activity seeds. The typical permanent
implant dose rate is less than 0.2Gyh1 using
low-activity seeds. For I-125, RBE values of
1.151.20 are observed for temporary implants,
and higher RBE values (up to 2) are observed in
permanent implants.
The dose D and biologically effective dose
(BED) of temporary implants can be calculated as
D (t ) =
Compared with higher-energy X-rays, low-

energy X-rays have a higher linear energy transfer
(LET), which associates with higher relative
biological effectiveness (RBE), an advantage in
terms of tumoricidal effect [28]. Typical energies
of the low-energy brachytherapy discussed in this
(9)
1
D ( 0 ) (1 e l t )
l
2 D ( 0 ) l
1 +
( m l )( a / b ) (1 e l t )
1 1 el t 1
) ( m + l ) 1 e ( m + l )t
2l (
= 78.83 cGy.
linical Applications of
C
Low-Dose Brachytherapy
1
D ( 0 ) (1 - e - l t ) ,
l

BED =
= 0.0384 1.44 1425.6
Note the above-calculated doses are from one

source only. The total dose to this point should be
summed from dose from all seeds.
37
(10)
[33, 34]. The total dose and BED of permanent

implants can be calculated as
D=
1
D (0) ,
l
D ( 0 )
1
BED = D ( 0 ) 1 +
l
( m + l )a / b

, (11)

where D ( 0 ) is the initial dose rate, =0.693/T1/2

is the decay constant, and is the recovery
constant for sublethal damage.
J. Yang et al.
38
While brachytherapy has a long history of

treating many tumors, such as cancers of the
cervix, oral cavity, lip, and penis, low-energy
brachytherapy did not start until new radioactive
sources became available. Because of its lower
-ray energy, radiation protection issues are
relatively easy to manage. The patient usually is
allowed visitors, and medical staff can care for
the patient with limited exposure to radiation.
Patients often can be treated as outpatients and
released shortly after the procedure.
The half-life is also important in the choice of
isotope for practical purposes. The half-life
should be long enough to allow sufficient time
for shipping, assays, and the clinical procedure.
On the other hand, the half-life used in permanent
implantations should be fairly short to minimize
time of exposure for relatives of the patient and
members of the public.
Since the dose rate falls off as the inverse
square of distance from the seeds and penetrating
power is lower, a highly heterogeneous tumoricidal dose is delivered within the target, and the
dose to the tissue outside the implanted volume
falls off rapidly. This is an obvious advantage of
brachytherapy compared with external beam radiation and often allows a high prescription dose to
be delivered with fewer radiation complications.
However, the seeds have to be placed directly
inside or very close to the target, which generally
requires an invasive procedure. Compared with
higher-energy brachytherapy isotopes (Cs-137,
Co-60, Ir-192, etc.), each low-energy seeds irradiate a relatively smaller target volume, and many
seeds are commonly used for a large treatment
volume. The most prominent application of lowenergy brachytherapy is permanent seed implant
of prostate adenocarcinoma using I-125 or Pd-103
encapsulated sources (seeds), with the choice
determined by the physician or patient. The typical prescribed minimal peripheral doses are
145Gy for monotherapy with 110Gy boost for
I-125 seeds and 110130Gy monotherapy with
100Gy boost for PD-103 seeds. The patient is
usually placed in an extended lithotomy position
under anesthesia to allow transperineal needle
insertion under the image guidance of
TRUS.Based on the patient-specific treatment
plan, from 60 to 120 seeds are injected into the
prostate gland using 10 to 20 needles. The procedure and clinical aspects are discussed in another
chapter of this book.
Temporary implants using eye plaques treating
choroidal melanoma is another well-established
clinical application. The pre-assayed seeds are
placed inside a gold or lead plaque, which shields
the extraocular tissues behind. The plaque is sewn
on the outside of the eyeball to irradiate the intraocular target for a few days. After comparing various isotopes (Ra-226, Au-198, Co-60, Ir-192, and
I-125, as well as tantalum-182 and ruthenium-10),
the Collaborative Ocular Melanoma Study chose
I-125 ophthalmic plaque radiation therapy to treat
medium-sized choroidal melanomas. In the study,
85Gy was prescribed at the apex of tumor for 37
days at a dose rate of 0.421.05Gyh1 [35, 36].
Some researchers chose to deliver the apical dose
of 73.3Gy over 57 days using Pd-103 and
reported a favorable outcome [3739]. The procedure and clinical aspects are discussed in another
chapter of this book.
References
1. Li Z, Das RK, DeWard AL etal (2007) Dosimetric
prerequisites for routine clinical use of proton emitting
brachytherapy sources with average energy higher
than 50 kev. Med Phys 34(1):3740
2. Butler WM, Bice WS, DeWerd LA etal (2008) Third-
party brachytherapy source calibrations and physicist
responsibilities: report of the AAPM Low Energy
Brachytherapy Source Calibration Working Group.
Med Phys 35(9):38603865
3. Nath R, Bice WS, Butler WM etal (2009) AAPM recommendations on dose prescription and reporting
methods for permanent interstitial brachytherapy for
prostate cancer: report of Task Group 137. Med Phys
36(11):53105322
4. Chiu-Tsao ST, Astrahan MA, Finger PT (2012)
Dosimetry of (125)I and (103)Pd COMS eye plaques
for intraocular tumors: report of Task Group 129 by
the AAPM and ABS.Med Phys 39(10):61616184
5. Blasko JC, Grimm PD, Ragde H (1993) Brachytherapy
and organ preservation in the management of carcinoma of the prostate. Semin Radiat Oncol 3:230239
6. Holm HH, Juul N, Pedersen H etal (1983)
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130:283286
7. Smith RP, Schuchert M, Komanduri K etal (2007)
Dosimetric evaluation of radiation exposure during
I-125 vicryl mesh implants: implications for ACOSOG
z4032. Ann Surg Oncol 14(12):36103613

8. Lemoigne Y, Caner A (eds) (2009) Radiotherapy and
brachytherapy. Springer, Dordrecht
9. Venselaar J, Baltas D, Meigooni AS etal (eds) (2012)
Comprehensive brachytherapy: physical and clinical
aspects. CRC Press, Boca Raton, FL
10. Sina S, Faghihi R, Meigooni AS etal (2011) Impact of
the vaginal applicator and dummy pellets on the
dosimetry parameters of Cs-137 brachytherapy
source. JAppl Clin Med Phys 12:3480
11. Williamson JF, Brenner DJ (2008) Physics and biology of brachytherapy. In: Halperin CE, Perez CA,
Brady LW (eds) Perez and Bradys principles and
practice of radiation oncology. Lippincott Williams &
Wilkins, Philadelphia, pp423475
12. TG144.http://www.aapm.org/pubs/reports/RPT_144.
pdf
13. Loftus TP (1984) Exposure standardization of 125I
seeds used for brachytherapy. JRes Nat Bur Stand
89:295303
14. Kubo H (1985) Exposure contribution from Ti K x
rays produced in the titanium capsule of the clinical
125I seed. Med Phys 12:215220
15. Seltzer S, Lamperti P, Loevinger R etal (1998) New
NIST Air-kerma strength standards for I-125 and
Pd-103 brachytherapy seeds. Med Phys 25:A170
16. Williamson J(1988) Monte Carlo evaluation of specific dose constants in water for 125I seeds. Med Phys
15:686694
17. Kubo HD, Coursey BM, Hanson WF etal (1998)
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18. Williamson JF, Butler W, DeWerd LA etal (2005)
Recommendations of the American Association of
Physicists in Medicine regarding the impact of
implementiong the 2004 Task Group 43 report on
Dose Specification for Pd-103 and I-125 interstitial
brachytherapy. Med Phys 32:14241439
19. Willliamson JF, Coursey BM, DeWerd LA etal (1999)
Guidance to users of Nycomed Amersham and North
American Scientific, Inc., I-125 interstitial sources:
dosimetry and calibration changes: recommendations
of the AAPM RTC ad hoc committee on low-energy
seed dosimetry. Med Phys 26(4):570573
20. Nath R, Anderson LL, Luxton G etal (1995)

Dosimetry of interstitial brachytherapy sources:
report of the AAPM Radiation Therapy Committee
Task Group 43. Med Phys 22(2):209234
21. Rivard MJ, Coursey BM, DeWerd LA etal (2004)
Update of AAPM Task Group no. 43 report: a revised
AAPM protocol for brachytherapy dose calculations.
Med Phys 31(3):633674
22. Daskalov GM, Kirov AS, Williamson JF (1998)

Analytical approach to heterogeneity correction factor
calculation for brachytherapy. Med Phys 25(5):
722735
23. Chen Z, Bongiorni P, Nath R (2010) Impact of source-
production revision on the dose-rate constant of
131Cs interstitial brachytherapy source. Med Phys
37(7):36073610
39
24. Frank SJ, Tailor RC, Kudchadker R etal (2011)

Anisotropy characterization of I-125 seed with
attached encapsulated cobalt chloride complex
contrast agent markers for MRI-based prostate
brachytherapy. Med Dosim 36(2):200205
25. Gautam B, Parsai EI, Shvydk D etal (2012)

Dosimetric and thermal properties of a newly developed thermobrachytherapy seed with ferromagnetic
core for treatment of solid tumors. Med Phys 39(4):
19801989
26. Rivard MJ, Reed JL, DeWerd LA (2014) 103Pd

strings: Monte Carlo assessment of a new approach to
brachytherapy source design. Med Phys 41(1):011716
27. Rivard JM, Butler WM, DeWerd LA etal (2007)
Supplement to the 2004 update of the AAPM Task
Group No. 43 Report. Med Phys 34(6):21872205
28. Eckerman MB (2013) Relative biological effectiveness
of low-energy electrons and photons, letter report.
U.S.Environmental Protection Agency October
29. Ling CC, Li WX, Anderson LL (1995) The relative
biological effectiveness of I-125 and Pd-103. Int
JRadiat Oncol Biol Phys 32:373378
30. Scalliet P, Wambersie A (1988) Which RBE for iodine
125in clinical applications? Radiother Oncol 9:221230
31. Wuu CS, Zaider M (1998) A calculation of the relative biological effectiveness of 125I and 103Pd
brachytherapy sources using the concept of proximity
function. Med Phys 25:21862189
32. Wuu CS, Kliauga P, Zaider M etal (1996)

Microdosimetric evaluation of relative biological
effectiveness for palladium-103, iodine-125, americium 241 and iridium 192 brachytherapy sources. Int
JRadiat Oncol Biol Phys 36:689697
33. Dale RG (1985) The application of the linear quadratic dose-effect equation to fractionated and protracted radiotherapy. Br JRadiol 58:515528
34. Gagne NL (2012) Radiobiology for eye plaque

brachytherapy and evaluation of implant duration and
radionuclide choice using an objective function. Med
Phys 39:33323342
35. Earle JD (1987) Selection of iodine 125 for the collaborative ocular melanoma study. Arch Ophthalmol
100:763764
36. Melia BM, Abramson DH, Albert DM etal (2001)
Collaborative ocular melanoma study (COMS) randomized trial of I-125 brachytherapy for medium choroidal melanoma. visual acuity after 3 years COMS
report no. 16 Collaborative Ocular Melanoma Study
Group. Ophthalmology 108:348366
37. Dolan J, Li Z, Williamson JF (2006) Monte Carlo and
experimental dosimetry of an I-125 brachytherapy
seed. Med Phys 33(12):46754684
38. Finger PT, Berson A, Ng T etal (2002) Palladium-103
plaque radiotherapy for choroidal melanoma: an
11-year study. Int JRadiat Oncol Biol Phys
54:14381445
39. Finger PT, Chin KJ, Duvall BS etal (2009) Palldium-103
ophthalmic plaque radiation therapy for choroidal
melanoma: 400 treated patients. Ophthalmology 116:
790796
Balloon Brachytherapy Physics

Dorin A. Todor
Abstract
Brachytherapy utilizing intracavitary balloon and strut devices is a recent

therapeutic offering. As such, the specifics of the physics of what might
appear superficially to be simple devices can be quite challenging. We
present this chapter to explain the balloon device and its physical
properties, including the nuances that may arise in planning and quality
assurance.
Introduction
Accelerated partial breast irradiation (APBI)

treatments can be delivered using external beam
or brachytherapy techniques. Interstitial
brachytherapy using low-dose-rate (LDR) Ir-192
seeds was historically the first modality used for
APBI and consequently has the longest follow-up.
More recently, external beam treatment has been
used, either as photon beams or highly collimated
electron beams, the latest being more often
associated with intraoperative techniques
relatively popular in Europe. New brachytherapy
sources have been developed, one example being
the miniature low-energy (~50 kV) source known
as electronic brachytherapy, but existent sources
D.A. Todor, PhD

Department of Radiation Oncology, Virginia
Commonwealth University Health System,
Richmond, VA, USA
(e.g., Pd-103) commonly associated with treatment of prostate cancer are also used as permanent seed implant for permanent breast seed
implant (PBSI) [13]. However, most commonly
(at least in the USA), APBI is associated with
high-dose-rate (HDR) treatment using Ir-192.
The relatively high-energy source (~380 keV) at
the tip of a thin wire is placed, using a computercontrolled afterloader device, in precisely specified positions for time intervals determined in the
planning phase. Given the fact that the treatment
is delivered quickly compared with the average
half-life of cellular repair processes, one can
establish an equivalence between multiple
sources loaded simultaneously (LDR) and one
source which is the case for the HDR paradigm,
being placed in specified positions called dwell
positions, along applicators, and kept for wellspecified amounts of time called dwell times.
Thus, for a well-determined target and a specified
applicator typically inserted close to the site to be
treated and a given strength of an Ir-192 source,

DOI 10.1007/978-3-319-26791-3_5
41
D.A. Todor
42
an HDR treatment plan consists of specifying

dwell positions and their associated dwell times.
Since the radioactive source is placed in the body
but cannot come in contact with tissues, one has
to use an applicator to both contain and to
guide the source in the desired positions. The
simplest applicator is a plastic catheter inserted
in the tissue, and a multitude [1524] of such
well-spaced catheters is called an interstitial
implant. Each catheter is connected to a channel
in the afterloader using a transfer (or guide) tube.
The first technique developed for APBI was
the multi-catheter interstitial brachytherapy [4].
With this approach, the treatment time is reduced
from the traditional 57 weeks to 58 days or less.
The technique was initially used to deliver a tumor
bed boost after whole breast irradiation, and it has
been one of the most used methods for APBI in
North America and Europe. Catheters are placed
through the breast tissue surrounding the lumpectomy cavity typically at 11.5 cm intervals. The
number of catheters is determined by the size and
shape of the target, and the configuration of the
catheters is guided by the understanding of
brachytherapy dosimetry. Initially, the target volume was defined as the lumpectomy cavity plus a
2 cm margin, except where these target dimensions were limited by the extent of breast tissue
(i.e., chest wall and skin). One has to remember
though that initially the catheter placement was
guided by fluoroscopy (with surgical clips placed
to mark the lumpectomy cavity), while the planning was based on orthogonal radiographs, so no
true planning target volume (PTV) was actually
defined.
Even though from a technical perspective, the

interstitial implant is the most flexible technique,
it does require specialized training and
considerable experience. In an effort to make
APBI more accessible, a number of devices were
created with the goal of reducing the level of
invasiveness, making the technique simpler and
more reproducible [4, 5]. Essentially, there are
two categories of devices: balloon-based devices
(MammoSite, Contura MLB, and MammoSite
ML) and strut-based devices (SAVI,
ClearPath). MammoSite, historically the first
balloon device for breast brachytherapy, was in
fact following in the footsteps of another balloon
device for brain brachytherapy: GliaSite RTS
a balloon filled with liquid I-125 [6].
1.1
Description of Devices
Available
MammoSite is a silicone balloon that can be

placed in a lumpectomy cavity and then inflated
with water to a diameter of 45 cm. It has a
15 cm long central shaft and a 0.6 cm diameter
that contains a larger treatment channel for
placement of the high-dose-rate source and a
smaller channel used for inflation (Fig. 1).
Given the central placement of the lumen, the
dose distribution created by one or multiple
dwell positions is always cylindrically symmetrical. The lack of symmetry of the central lumen
relative to the balloon or the asymmetry of the
PTV (due to closeness to skin or chest wall)
could only be dealt with by the MammoSite
Radiation source
port pathway
Inserted obturator to
prevent bending or
coiling of the catheter shaft
Multilumen, silicone catheter
Variable 4 5 cm balloon
Fig. 1 MammoSite
balloon
Needless injection site
RTS by compromising target coverage or dose

to the critical normal structures (skin and chest
wall). Given that the prescription dose is always
at 1 cm from the surface of the balloon, the
radius of the balloon will influence dose to
the surface of the balloon and consequently the
dose gradient in the target. For a medium-sized
balloon (diameter of about 4.5 cm), the dose to
the surface of the balloon is approximately
200 % of the prescription dose, with slightly
smaller values for a larger diameter balloon and
slightly larger values for a smaller diameter balloon. A slight anisotropy of dose along the
direction of the wire (picture an apple vs. an
orange at the north and south pole) can be
reduced by the use of multiple dwell times [7].
The theoretical advantage of using the largest
possible balloon diameter is that it allows one to
create a more homogeneous dose distribution.
However, some centers have noticed higher
rates of seroma formation and fat necrosis with
higher balloon fill volumes.
Because treatment planning is performed
under the conditions of an inflated balloon, it is
critical that the integrity of the balloon is verified
prior to each fraction to avoid delivery of higher
than intended doses directly to the surrounding
breast tissue. Typically such verification is done
using ultrasound, fluoroscopic, or CT images.
For the central lumen balloon, there is a tight
coupling between dose coverage of the target
and dose to organs at risk (OARs). An attempt
to decrease the dose to an organ at risk when
using only central lumen balloons will unavoidably decrease the dose to the target. The lack of
flexibility in planning with the central lumen
only balloon device leads to the creation of the
multi-lumen devices: Contura MLB and
MammoSite ML. Both devices preserved the
central lumen but added offset treatment
lumens. The Contura MLB also has two vacuum ports at the distal and proximal aspects
that can be used for removal of air and fluid
thus increasing conformity of the tissue to the
surface of the balloon (Fig. 2a, b). The major
advantage of the multi-lumen devices is that
they decouple the dose coverage of the target
from minimizing the dose to critical structures.
43
A treatment plan for an asymmetric target can

now simultaneously maximize the prescription
dose coverage while minimizing dose to skin
and chest wall. The penalty comes in the
form of creating an asymmetric dose distribution (which conforms very well to the asymmetric target) outside a symmetric balloon, thus
increasing the volume of tissue in the target
receiving a larger than prescription dose (e.g.,
V200, the volume of the target that receives
200 % of prescribed dose).
Even though initially developed by different
companies, all three balloon devices commercially available are now offered by the same
company (Hologic Inc., Bedford, MA):
MammoSite single-lumen balloon catheter
(in two sizes, 4.05.0 cm and 5.06.0 cm),
MammoSite multi-lumen (ML) balloon catheter (3.55.0 cm), and Contura multi-lumen
balloon (MLB) (also in two sizes, 4.05.0 cm
and 4.56.0 cm). For each device, a balloon
device is offered for cavity size evaluation, the
Cavity Evaluation Device (CED) which is
placed at the time of the lumpectomy and
replaced with a treatment balloon at the time of
treatment. The MammoSite device consists of
a silicone balloon connected to a catheter
(Fig. 1). The balloon is inflated with saline
solution and a small amount of radiographic
contrast to aid visualization. The designs of the
multi-lumen balloon applicators are different.
The Contura MLB has five lumens, one central lumen and four equally spaced peripheral
lumens which are 0.5 cm away (at their largest
separation) from the central lumen (Fig. 2b).
The MammoSite ML has four lumens: one
central lumen and three equally spaced peripheral lumens, parallel with and at 0.3 cm from
the central lumen (Fig. 3a, b). Another balloon
applicator, with just a central lumen, was developed in conjunction with the 50 kV electronic
brachytherapy source Axxent EBT system
(Xoft, Inc., Sunnyvale, CA) (Fig. 4). Other than
the size of the central lumen designed to accommodate the much larger X-ray source and its
cooling housing, there is nothing else that
would distinguish the Axxent from the
MammoSite balloon.
D.A. Todor
44
Fig. 2 (a, b) Contura
MLB
5 treatment
lumens
Vacuum ports
Orientation line
Applicator
Vacuum luer
Inflation luer
Radiation source
lumens
Stiffening stylet
1.2
192
Radiation Sources
for Breast HDR
Iridium has long been the workhorse of brachytherapy. The history starts with iridium in seed
form having been used in brachytherapy in 1958
by Ulrich Henschke and then, from the early
1960s, mainly as wires [8]. Andrassy, in a debate
on the best HDR isotope, sets up the history,
pointing out the fact, sometimes forgotten that
there was a time when most afterloaders used

cobalt-60: In the 1950-60s, when the production
of isotopes by neutron activation became feasible, Co-60 complemented Cs-137 as the standard
nuclide in radiation therapy. Its application has
been studied in many countries all over the world,
and broad clinical experience in teletherapy, as
well as in brachytherapy has been gained. All in
all, several hundred HDR afterloader units
equipped with Co-60-sources have been utilized

Fig. 3 (a, b) MammoSite
ML
45
Variably
inflatable balloon
Inflation lumen/
fluid port
Steel stylet
4 source
pathway lumens
Depth markers
Obturators
Labeled device
b
LUMEN #1
120 00*
2.0 mm
LUMEN #1
LUMEN #2
LUMEN #3
Inflation lumen/
fluid port
Fig. 4 Axxent
applicator
in clinics ever since, the majority of them for

gynecological applications. The technical
development of sources with higher specific
activity was the starting point for HDR remote
afterloading. Clinical data and dose delivery concepts to achieve equivalent outcomes in Low
Dose Rate (LDR) and HDR-applications had
been worked out using Co-60 sources. In the
46
1970s, the manufacture of miniaturized 192Ir

sources shifted market preference to this nuclide.
Smaller size and source diameter allowed new
application modalities, e.g. interstitial therapy, as
well as dose optimization due to stepping source
technology. At the same time, the extrapolation
of experience obtained from traditional brachytherapy nuclides to Ir-192 was based on the
similarity of physical dose distributions [9].
192
Iridium has a reasonably long half-life
(73.81 days) so a typical source exchange occurs
approximately every 2 months. Two other technical advantages are a relatively low average energy
(~.38 Mev, with a range from 0.136 to 1.062 MeV)
and a half value layer of ~0.3 cm Pb so it is relatively easily shielded. Nevertheless, the lead
shielding for a room designated solely for brachytherapy can be expensive. The other advantage is
its high specific activity (450 Ci/g) allowing the
construction of high activity sources (10 Ci) of
small diameter (0.060.11 cm). 192Ir is produced
from enriched 191Ir targets (37 % natural abundance) in a reactor by the (n, ) reaction, creating
HDR 192Ir sources (typically 0.1 cm diameter by
0.35 cm length cylinders) with activities exceeding 4.4 TBq. High-dose-rate 192Ir sources are
encapsulated in a thin titanium or stainless steel
capsule and laser welded to the end of a flexible
wire. Electrons from -decay are absorbed by the
core and the capsule.
Instead of using HDR 192Ir, the Xoft Axxent
source is an electronic microminiature X-ray
tube [1]. Despite a small diameter of the X-ray
tube 0.225 cm the need for a flexible cooling
catheter makes the HV catheter 0.54 cm large
enough to make its use impossible in most, if not
all, applicators designed for 192Ir. The electronic
source generates a 50-kV photon spectrum in a
roughly spherical distribution. The depth dose
characteristics of this source were designed to
roughly mimic HDR 192Ir; however, there are
important differences. The lower photon energy
of this source results in greater attenuation.
Unlike HDR 192Ir, electronic brachytherapy
(EBB) does not require a shielded vault. This
reduces costs and allows for portability of the
system, which can lead to greater access for
patients particularly in more remote locations or
D.A. Todor
non-shielded operating and treatment rooms.

There are also dosimetric implications of a lowerenergy spectrum that results in more rapid dose
falloff with depth in tissue. With a standard dose
prescription at 1 cm from the balloon surface, the
dose to structures proximal to this point is higher,
and the dose to structures beyond this point is
lower with EBB. Dickler et al. evaluated the
dosimetric differences between Xoft and
MammoSite [10]. They showed that the dose to
lung and heart was significantly lower with
EBB. The lung V30 was 1.1 % vs. 3.7 % and
heart V5 of 9.4 % vs. 59.2 % for EBB and
intracavitary breast brachytherapy (IBB),
respectively. The dose to nontarget breast was
also lower; breast V50 was 13 % vs. 19.8 %,
respectively. However, the volume of dose
hotspots was significantly higher with EBB. The
V150, V200, and V300 were 59.4 % vs. 41.8 %,
32 % vs. 11.3 %, and 6.7 % vs. 0.4 %, respectively.
Another consideration for EBB is that the relative
biological effectiveness (RBE) for low-energy
photons is higher on the order of 1.22, depending
on energy and depth. This has currently not been
taken into account in the prescribed dose for
EBB, which uses the same prescription of
34.0 Gy in 10 fractions as used with IBB using
HDR 192Ir. Electronic sources do not fall under
existent regulatory scrutiny of radioactive
sources. The American Society for Radiation
Oncology (ASTRO) Emerging Technology
Committee issued a report on electronic
brachytherapy providing a descriptive overview
of the technologies current and future projected
applications,
comparison
of
competing
technologies, potential impact, and potential
safety issues [11].
169
Ytterbium has been mentioned for a long
time as a possible alternate HDR source and the
advantages of Yb-169 compared with Ir-192 for a
balloon device have been described [12].
169
Ytterbium emits photons with energies ranging
from 50 to 308 keV (average energy 93 keV) and
decays with a half-life of 32 days. While the
shorter half-life is a disadvantage, the lower
average energy clearly would require significantly
less shielding than iridium. In the balloon study,
the plans using 169Ytterbium source results in less
volume receiving doses of 150 and 200 % of the

prescription, a greater dose homogeneity index
(DHI), and lower maximum dose [12]. The X-ray
source performed worse in all categories.
1.3
Process Description
Once a patient has been identified as an

appropriate candidate for APBI, one has to assess
the appropriateness of balloon brachytherapy.
The patient typically undergoes a CT or
ultrasound of the involved breast, and the options
are discussed in a multidisciplinary team
involving a surgeon, radiation oncologist, and
physicist. A balloon is deemed a suitable choice
if the lumpectomy cavity is situated in a region of
the breast where there is enough surrounding
tissue to allow the inflation of a balloon (the
typical diameter is between 4 and 6 cm). After
placement under ultrasound (US) guidance, other
conditions are necessary or desirable: a balloonto-skin distance 0.3 cm or more (preferably
0.7 cm), good conformance of the balloons
surface to the walls of the lumpectomy cavity,
and, for a single-lumen device, (MammoSite)
balloon symmetry around the catheters center
shaft. Patients are excluded if the cavity is
excessively large, if there is poor conformance of
the balloon to the cavity walls or inadequate
balloon-to-skin distance.
Zannis et al. identified three different techniques for insertion of a breast brachytherapy balloon catheter [13]: (1) at the time of lumpectomy
into an open cavity, (2) after surgery with ultrasound guidance through a separate small lateral
incision into a closed cavity, or (3) after surgery
by entering directly through the lumpectomy
wound (the scar entry technique). Analyzing clinical outcomes after each of the insertion methods,
they concluded There was a statistically significant increased incidence of premature catheter
removals for pathologically related reasons with
the open-cavity technique compared with the 2
postoperative methods secondary to final histology reports disqualifying the patient after placement. Thus, postoperative placement, after the
final pathology report is issued, decreases the
47
incidence of premature removal of the catheter

because of disqualifying pathology.
The ultrasound-guided placement technique
takes place after surgery and uses ultrasound
visualization of the lumpectomy cavity. After
skin and subcutaneous tissue infiltration with
lidocaine solution, a sharp metal trocar provided
by the manufacturer is inserted with ultrasound
guidance into the lumpectomy cavity through a
small skin incision made in the lateral breast. The
cavity seroma decompresses through the trocar
lumen, the trocar is removed, and then the
deflated balloon catheter is inserted into the
cavity through the trocar tract or using a split
sheath. Using a syringe with a saline and contrast
solution, the balloon is progressively inflated.
Another CT or ultrasound is taken to ensure the
conformity of the balloon to the lumpectomy
cavity, to estimate the balloon-to-skin distance,
and to make sure that the balloon catheter is in an
optimal position. A photograph is taken at the CT
time and used to verify catheter position before
each fraction. A reference mark is placed on the
breast commensurate with the index mark on
multi-lumen balloons to verify correct positioning
in the event of rotation of the device. A planning
CT is used for treatment planning and dose
optimization. The plan is verified, applicator
treatment lengths are measured, and treatment is
administered in the planned number of fractions
(typically 10 fractions of 3.4 Gy) using a 192Ir
computer-controlled remote afterloader. Prior to
each fraction, the integrity of the balloon (its size/
diameter) is verified using ultrasound,
fluoroscopy, CT, or CBCT, along with the
rotational position. After the last treatment is
delivered, the balloon is deflated and the balloon
catheter removed and incision closed. Rotation of
the balloon in the breast prior to explantation
breaks adhesions and facilitates the removal.
1.4
Target Delineation in Balloon

Brachytherapy
The vast majority of authors describing early

experience with interstitial implants report a
clinical target volume (CTV) defined as
D.A. Todor
48
lumpectomy cavity + 2 cm [4, 14, 15]. It is not

clear when the accepted interstitial margin
became 1.5 cm, but most likely it is related to the
CT-based planning, when careful, systematic,
reproducible, and true three-dimensional volumes were created. It is also likely that it occurred
at the time of the National Surgical Adjuvant
Breast and Bowel Project (NSABP) protocol
B-39 [16] writing. The 1.5 cm was chosen as a
compromise between the 2 cm margin for interstitial implants and the 1 cm margin for the new
balloon applicator that was to be included in the
brachytherapy arm of the trial.
When the balloon brachytherapy method
using MammoSite was introduced, Edmundson
et al. made a point in demonstrating, using the
concept of effective thickness, that the target
irradiated by the MammoSite was in fact
nearly 2 cm [17]. This demonstrates that at the
time (2002) the 2 cm margin was still the accepted
margin for interstitial implants. Dickler et al. also
calculated the effective thickness for 13 patients
and produced a mean result of 1.6 cm [18]. These
results were consistent with the CTV margins
used for multi-catheter interstitial brachytherapy,
supporting the hypothesis that the two APBI
modalities treat effectively similar target volumes. Dicklers paper was published in 2004,
therefore sometime between 2002 and 2004 the
margin for interstitial implants was transformed
from 2 cm to 1.5 cm.
A more recent paper, acknowledging the fact
that the effective thickness might not be uniform
due to the fact that the tissue adjacent to the balloon may compress or stretch, used deformable
registration to propagate contours from one CT
set to another [19]. Their conclusion was that
The effective CTV treated by the MammoSite
was on average 7 % 10 % larger and 38 % 4 %
smaller than three-dimensional conformal radiotherapy (3DCRT) CTVs created using uniform
expansions of 1 and 1.5 cm, respectively. The
average effective CTV margin was 1.0 cm, the
same as the actual MammoSite CTV margin.
However, the effective CTV margin was nonuniform and could range from 0.5 to 1.5 cm in
any given direction.
Contouring of CTV is known to be associated
with low interobserver concordance, due to a
number of factors: dense breast parenchyma,
benign calcifications in the breast, and tissue
stranding from the surgical cavity. Surgically
placed clips after lumpectomy as radiographic
surrogates of the cavity have been shown to help
with the delineation of the lumpectomy cavity. In
balloon-based methods, the uncertainty of delineating the lumpectomy cavity is removed and
replaced by the much more reliable delineation of
the balloon surface. Of course the implicit
assumption is that the balloon is correctly placed
in the center of lumpectomy cavity and that the
inflated balloon stretches the tissue isotropically.
For increased visibility on CT images and automatic delineation, a small quantity of iodinebased contrast is used in the water. A planning
target volume for evaluation (PTV_EVAL) is created using a 1.0 cm expansion from the balloon
surface of the CTV but limited by the first 0.5 cm
from the skin surface and abutting the chest wall.
A 1 cm expansion is used in the case of balloonbased brachytherapy devices due to stretching of
the tissue surrounding the lumpectomy cavity. A
majority of the seroma will be expelled during the
placement of the brachytherapy applicator. Some
additional fluid may be present at the time of simulation and may be removed using the devices
vacuum port, if available. Time will also almost
always allow for resorption or dissolution of fluid
and air. Waiting 12 days before treatment usually
remedies the issue. If air or fluid is retained within
the lumpectomy cavity after inflation of the applicators balloon, the displacement of the tissue
away from the applicators surface must be
accounted for. The air/fluid trapped should be
contoured separately on each CT slice and a total
volume should be calculated to determine the percentage of the PTV_EVAL that is displaced. This
percent displacement must be limited so that:
( % PTV _ EVAL coverage ) ( vol. trapped air / vol PTV _ EVAL ) 100 = 90%
The PTV_EVAL originated as a structure used to

evaluate an existent plan for APBI under the
NSABP B-39 clinical trial (also known as the
Radiation therapy Oncology Group (RTOG) trial
0413). The simple idea was that since the external beam (EB) dose calculation algorithms were
unreliable close to interfaces (i.e., skin) and since
the trial was supposed to compare brachytherapy
and external beam treatments, creating a structure that would remove the 0.5 cm of skin seemed
almost normal. The pectoralis muscle, chest wall,
and ribs were deemed nontarget tissues and
also removed from the PTV.
While the PTV, as a 1 cm margin from the balloon surface, would almost always be symmetrical
(unless the balloon would be less than 1 cm away
from the skin), the PTV_EVAL, by being limited by
the 5 mm skin structure and the chest wall and pectoralis, would be, in many cases, asymmetric. In the
49
MammoSite era, there was nothing one could do

to customize the coverage for an asymmetric PTV_
EVAL. Whether the PTV would be whole as in
the case of a balloon placed deep in the breast or
chopped (Fig. 5), the dose distribution created
was invariably a radially symmetrical blob. So even
though there were no two explicit structures, one for
planning and one for evaluation (as that was the
case, e.g., in EBRT), there was in fact an implicit
planning structure simply because the device could
only create a radially symmetrical dose distribution.
With the advent of multiple treatment lumens,
which have the potential to create a dose distribution truly conformal to the PTV_EVAL, the question whether PTV_EVAL is in fact a planning
structure, an evaluation structure, or both should be
revisited. The answer is far from being of just academic interest and more likely has important implications for how the new devices are being used.
Fig. 5 Orthogonal views of a Contura Multi-lumen plan. In yellow are the bounding planes of the PTV_EVAL
D.A. Todor
50
A planning exercise using Contura balloons

attempted to elucidate the implications of removing the 0.5 cm of skin from the PTV on dosimetric parameters currently reported (Todor D, 2007,
personal communication).
A classic PTV_EVAL is shown in Fig. 6.
The uniform 1 cm expansion of the balloon is
limited by both the pectoralis muscle and 0.5 cm
of the skin layer. The novel PTV_EVAL is
shown for the same anatomy as above (Fig. 7).
One can see (in bright red contours) that in its
anterior aspect, the novel PTV_EVAL is now
limited by the skin surface.
Two plans were created per patient, each optimizing the coverage for its intended structure.
The coverage of each intended target for the two
plans was similar (within 1 %), so meaningful

conclusions can be drawn for all other parameters. Dosevolume histogram (DVH)-based optimization with constraining pseudo-structures
was employed in all cases. By including the
0.5 cm of skin in the PTV_EVAL, the volume of
this structure increased by up to 20 %. Despite an
increase in target volume, when the dose is correctly optimized, the dose received by breast tissue is very similar with a slight increase (14 %)
for the larger PTV_EVAL. So, even though one
outlined and optimized on a different structure,
the volume of breast tissue receiving prescription
dose was virtually the same. The one parameter
clearly different was the maximum dose to the
skin: for the NSABP B-39 PTV_EVAL, the max
dose to skin was between 11 and 17 % lower than
for the larger PTV_EVAL, even though in all
cases it was kept under 125 % of prescription.
1.5
Fundamentals of Physics
The physics of balloon brachytherapy is in no way

different from the physics of brachytherapy in
general. In fact, while essential to our understanding of dose delivered to target tissues, physics is
one component in a long list of ingredients necessary for a successful brachytherapy treatment.
Without the claim that this is an exhaustive one,
here is a comprehensive list of such ingredients:
Fig. 6 A classic (NSABP-B49/RTOG 0413) PTV_EVAL
Fig. 7 A novel PTV_EVAL containing the 0.5 cm of

skin normally removed
1. One or more radiation sources with calibration traceable to a standard laboratory

2. Good understanding of the radiation emitted
by the sources and the effects of encapsulation, wires, etc.
3. Good dosimetric system/model for the computation of dose distribution and treatment time
4. Good understanding and good geometrical
and material description of applicators
5. Accurate positioning of sources
6. Accurate timing of source placement
7. Accurate description of tissues (composition
and mass energy absorption coefficients)
8. Accurate description of radiation biological
effects in the targeted tissues as well as
normal tissues
Distance (inverse-square law)

Absorption and scattering in the source core
and encapsulation
Photon attenuation
Scattering in the surrounding medium
The inverse-square law is the best known and
strictly geometric consequence of any isotropic
source emitting photons in a 3D space. It assumes
no attenuation or scattering of photons by the
medium. Of the four factors influencing the dose
distribution, the inverse-square law is by far the
most important. For a pure isotropic point source,
the dose will decrease by a factor of 100 between
the distances of 0.5 and 5 cm. The influence of the
remaining factors over the same distance range
rarely exceeds a factor of 2 or 3. The tissue surrounding the source affects the dose distribution in
two competing ways: dose is reduced by the attenuation of primary photons and at the same time is
increased by the scattered photons. Photons are
being emitted in all directions from the source and
are interacting with the tissue by means of Compton
scattering and photoelectric absorption. Thus, each
volume element of tissue is effectively radiating
scattered photons in all directions, many of which
contribute to the dose at the point of interest.
One can see that up to distances of about 5 cm,

the attenuation of primary photons and the
buildup of dose from scattered photons are
compensating each other, leading to an almost
pure inverse-square distance law (Fig. 8). At
larger distances, seldom of interest for clinical
purposes, attenuation wins and the falloff is
faster. Compton scattering, which dominates
photon absorption and scattering above 100 keV,
depends mainly on electron density (electrons/g)
of the medium, which is nearly constant for all
biologic materials. Thus, for 192Ir HDR
brachytherapy, tissue composition is largely
irrelevant, and water as a medium is a very good
approximation, validating the use of TG-43
formalism in most clinical applications. The only
limitation of TG-43 is assuming that medium is
infinite and thus scatter contribution is always in
full. In the evolution of brachytherapy treatment
planning, the authors examined the sensitivity of
common treatment sites to dosimetric limitations
of the current dose computation formalism
(TG-43) [20]. They concluded that for breast
HDR, significant differences between planned
and delivered dose are likely to occur due to one
factor only: scatter. In the breast, relatively close
to the radiation source and applicators are two
interfaces: one between the breast and air and the
other between breast tissue and the lung. As a
0.05
350 keV
4r 2 [D/R] [cm2 g1]
In August 2012, a report of the High Energy

Brachytherapy Source Dosimetry (HEBD)
Working Group published its Recommendations
of the American Association of Physicists in
Medicine (AAPM) and the European Society for
Radiotherapy and Oncology (ESTRO) on dose
calculations for high-energy (average energy
higher than 50 keV) photon-emitting
brachytherapy sources was presented, including
the physical characteristics of specific 192Ir, 137Cs,
and 60Co source models as well as consensus
datasets for commercially available high-energy
photon sources [11]. Without getting in the
details of the dose computation formalism and
radiation source descriptions within this
formalism, all of which are well described in
literature, we will address physics issues directly
related to balloon brachytherapy. In general, four
factors influence the single-source dose
distribution for photon-emitting sources:
51
0.04
Total dose
0.03
Pr
im
ar
Total-scatter
0.02
0.01
0.00
0
10
r [cm]
15
20
Fig. 8 Contributions of primary and scattered photons to

total absorbed dose at the photon energies of 350 keV. The
dose distributions are multiplied by the distance squared
and normalized to the primary photon energy (From
Carlsson and Ahnesj [43])
D.A. Todor
52
result, a part of the contribution from scatter will

be lost, and likely the planned dose will be an
overestimation of the dose actually delivered. It
is interesting to note that this is also applicator
dependent. In interstitial implants, the source is
in the immediate proximity of the tissue, thus
dose is delivered largely by primary photons and
thus the missing scatter will impact very little the
difference between planned and delivered dose
(typically 23 %). In balloon brachytherapy, the
tissue is a few cm away (as much as 34 cm)
from the source, making the scatter a more
important component of dose. Thus, the missing
scatter due to the breast tissueair interface can
bring the difference between planned and delivered dose to 1015 %.
1.6
Prescription Dose
and Fractionation Schedules
The whole breast treatment of standard breast

conservation therapy typically lasts 57 weeks
with daily treatments delivering a dose of
4550 Gy to the whole breast, sometimes
followed by a boost of 1016 Gy to the tumor bed
volume. Multi-catheter interstitial brachytherapy
is the APBI technique with the longest follow-up
and most mature data supporting APBI. It was
initially developed as a technique to deliver the
boost part of the treatment after whole breast
irradiation (WBI). A clinical trial, RTOG 9517,
evaluated interstitial brachytherapy as a sole
modality after lumpectomy. This was based on
the pioneering work at the Ochsner Clinic (New
Orleans, LA, USA) and the William Beaumont
Hospital (Royal Oak, MI, USA). Patients were
treated with LDR 192Ir at a dose of 45Gy over
4.5 days or HDR, with 34 Gy in 10 fractions over
5 days. In the era of interstitial implants,
alternative fractionation schemes were 4 Gy 8
fractions [21] and 4.33 Gy 7 fractions or
5.2 Gy 7 fractions [22]. There are a number of
MammoSite APBI series describing long-term
outcomes with a number of fractionation
schemes: 3.4 Gy 10 fractions [2325] and
7 Gy 4 fractions [26]. Ultrashort-course APBI
using the Contura device, with conservative
dosimetric parameters, is actively being

investigated in a phase II multi-institutional trial.
Early data using a fractionation regimen of 7 Gy
in four fractions (delivered twice daily) shows
tolerable rates of acute toxicities comparable to
typical APBI fractionation schemes [27]. Based
on the linear-quadratic model and acknowledging
its limitations, three ultrashort fractionation
regimens were developed using a multi-lumen
balloon device: 7 Gy 4 fractions, 8.25 Gy 3
fractions, and 10.5 Gy 2 fractions. A minimum
of 6 h was required between fractions, irrespective
of the fractionation schedule and very
conservative dosimetric criteria were defined.
Four-year results were presented using balloon
brachytherapy (MammoSite) delivered with a
2-day fractionation schedule [26]. In a recent
dosimetric study comparing HDR using 192Ir vs.
50 kV X-rays for breast intraoperative radiation
therapy the authors proposed using a multi-lumen
balloon to deliver 1 fraction of 12.5 Gy [28]. An
ongoing prospective clinical trial will evaluate
the safety and feasibility of this technique.
1.7
CT Planning and Dose

Optimization
Before discussing dose optimization, one needs to

stress the importance of optimal placement of the
device (s). While there are many constraints in
how a device (in this case a balloon) is being
implanted, many of them relate to patient anatomy and convenience, lumpectomy position
within the breast, and the position of OARs relative to lumpectomy. Optimal placement takes into
account the particularities of the device and the
way dose distribution is created. An example is
given in Fig. 4 for the Contura MLB. One can
see that the asymmetry of the PTV_EVAL can be
bounded by two lines (in yellow) in two of the
orthogonal views. Ideally, the central lumen
would be oriented along the bisector (upper panel
left) and catheters 1 and 3 would also be positioned along the bisector (lower panel right).
While the position of the shaft can be dictated (as
in this case) by the length of the tissue that needs
to be traversed to reach the cavity, there is no rea-
son not to rotate the balloon, once inserted, in

such a way to place it in an optimal position. If
catheters 13 are along the bisector and catheters
24 are oriented along the shorter axis of PTV_
EVAL, the planning system optimizer would very
likely weigh heavily on 13 in order to create an
elongated dose distribution, and it would use very
little catheters of 2 and 4. In a less than optimal
position, the optimizer would likely distribute
dwell times in all catheters, thus leading to a more
spherical, less conformal dose distribution.
A preliminary CT scan can be used for rotating the balloon in the optimal position. For the
final treatment planning of CT, the patient should
be in a supine position, and that position should
be reproduced in each of the treatments. Every
particular aspect (arm, wedges used to rotate the
patient, etc.) should be recorded and reproduced
in each of the treatment positions. The CT should
start at or above the mandible and extend several
cm below the inframammary fold (including the
entire lung) if one wants to develop comprehensive
DVH parameters. A CT scan thickness of
0.5 cm (preferably 0.20.3 cm) should be
employed. The following structures would be
contoured: the balloon surface, the clinical target
volume (CTV), the planning target volume
(PTV), PTV_EVAL, trapped air and/or fluid in
the cavity, and the ipsilateral breast. The chin,
shoulders, and entire ipsilateral breast would be
included in the scan. The target and normal tissue
structures must be outlined on all CT slices.
Immediately after the scan (or immediately
before), a photo should record the position and
orientation of the shaft relative to the incision.
Sometimes a small dot on the skin helps reproduce
the orientation prior to each treatment. Some
devices have built-in markers to help the planner
identify the catheter number. Contura, for
example, has a wire underneath catheter No. 1
(showing bright in Fig. 4). Radiopaque plugs at
the tip of each catheter help identify the most
distal point for the applicator. MammoSite ML
does not have any of these features, so the use of
at least a wire marker is absolutely necessary to
identify a reference offset catheter. Knowledge of
the device orientation and indexing of the offset
catheters can then help identify the other
53
catheters. Once a CT scan is obtained, the

planning phase includes delineation of anatomical
and planning structures, delineation of
applicators, establishment of allowed positions
for the radioactive source within applicators
(dwell positions), and dose optimization.
The balloon can be outlined (segmented)
automatically based on an increased CT number
compared with adjacent tissue (Fig. 9). This can
be easily achieved using a few milliliters of an
iodine-based dilute in the water or saline used to
inflate the balloon. The contour of the balloon
becomes a surrogate definition of the lumpectomy
cavity (gross target volume or GTV).The PTV_
EVAL is created by uniformly expanding the
balloon surface by 1 cm. The structure is limited
to 0.5 cm from the skin surface and limited to
exclude the chest wall and pectoralis muscles.
Very important for the planning for these types
of devices is an arbitrarily constructed avoidance
structure. The pseudo-structure is obtained by
expanding the PTV_EVAL by 0.30.4 cm then
subtracting the PTV_EVAL itself, resulting in a
thin rim surrounding the PTV_EVAL (Fig. 6).
Additional constraints can be imposed on this
structure, together with the ones already described
for the PTV_EVAL.
The next step is defining the geometry of the
applicators. For the balloon-based devices, the
rigid relative geometry of the treatment lumens
(e.g., Contura MLB, MammoSite ML) allows
the importing of an archived applicator from a
Fig. 9 Outline of a multi-lumen balloon after automatic

segmentation. Also shown are the applicators
D.A. Todor
54
template library, dramatically reducing the time

needed to outline the applicators and at the same
time insuring a perfect and reproducible definition
of the applicators even on less than optimal
quality images. Once applicators are delineated,
one defines the dwell positions by specifying, for
each catheter, the lumen or strut a starting dwell
position and a dwell increment (typically 0.5 cm
but it can be any value greater than 0.1 cm).
While there are many ways of creating a dose
distribution, among them, manual and geometrical
optimization, the only true optimization is the socalled volume or DVH-based optimization. Each
of the structures that will be subjected to dosevolume constraints is sampled in a number of points,
typically hundreds to thousands, depending on the
volume. The reason for doing this is that in order to
speed up the optimization process, one can choose
to calculate dose in a much smaller number of
points than the total number of dose voxels that the
structure inherently has, based on the resolution of
the dose matrix. While upper and lower constraints
are placed on the dosevolume histogram for the
target PTV_EVAL, the avoidance structure placed
outside the target is the one limiting higher than
prescription dose spilling into the normal tissue,
thus driving the dose conformance. Good structures and good constraints will produce optimal
plans. If one needs to manually tweak an already
optimized plan, it is very likely that either the optimizer is not performing adequately (might be too
sensitive and easily captured by local minima),
or the set of constraints does not adequately or
completely reflect the goals for the plan.
During volume optimization, dosevolume
constraints are placed on the histograms for
PTV_EVAL and the avoidance structure (an
example with typical constraints is shown in
Fig. 7). Depending on the shape of the PTV_
EVAL, one can limit the volume of the avoidance
structure receiving prescription dose to a small
percentage (110 %), thus increasing the
conformality of the dose to the PTV_EVAL. The
volume of the PTV_EVAL receiving 150 % PD
is, for a balloon-based device, depending on its
diameter, around 2530 % of the total volume.
Optimization of dose for a multi-catheter balloon device is clearly the best way to produce a
dose distribution conformal to an asymmetric

PTV_EVAL. Conformity implicitly means lowest
dose to the adjacent OARs. The cost for the best
dose coverage of the target and the best sparing of
OARs is an increase in V200. If one would
attempt to minimize V200, the best way to achieve
that would be to create a dose distribution for
which the 200 % isodose line falls either on the
surface of the balloon (thus conforming) or inside
the balloon, which is meaningless clinically. The
latter is only possible for large diameter balloons
where the distance between the prescription dose
(PD) isodose line and the 200 % PD isodose line
is slightly more than 1 cm, given the simple fact
that being farther away from the source places the
target in a region of gentler gradient. One cannot
simultaneously meet these two conflicting
requirements: a 200 % PD isodose conforming to
a symmetrical shape (the balloon) and a 100 %
PD isodose conforming to an asymmetric target
(PTV_EVAL). As a consequence, V200 will be
slightly increased but well under the 10 cm3 limit.
1.8
Dosimetry in Balloon
Brachytherapy: Outcome
Measures and Toxicity Analysis
Since the balloon devices are relatively new, the

short follow-up after balloon brachytherapy and
the constant evolution of the devices and accepted
dosimetry does not yet permit a definite judgment
concerning the long-term effectiveness of balloonbased APBI. NSABP B-39/RTOG 0413 A
Randomized Phase III Study of Conventional
Whole Breast Irradiation (WBI) Versus Partial
Breast Irradiation (PBI) for Women with Stage 0, I,
or II Breast Cancer is the key to answering the
question, Is partial breast irradiation (PBI) safe
and as effective as whole breast irradiation (WBI)
for these patients? Mature phase III data documenting the long-term efficacy of PBI and the
group of patients most suitable for its application
are not yet available. However, toxicities and side
effects tend to develop in a shorter time frame, and
as a result, a significant number of papers have
been published on this subject. Data about toxicity
and dosimetric limits associated with various side
55
effects originated after studying interstitial

implants, historically the first APBI modality. A
well-known paper by Wazer et al. analyzed variables associated with late toxicity such as longterm cosmetic outcome after high-dose-rate
interstitial brachytherapy [29]. They found that
suboptimal cosmetic outcome was significantly
associated with the number of source dwell positions, V150 and V200, and inversely associated
with DHI (0.77 vs. 0.73; p = 0.05). The risk of grade
1/2 skin toxicity was significantly associated with
V150 and V200 and inversely associated with DHI
(0.77 vs. 0.71; p = 0.009). The risk of grade 0/1 vs.
grade 24 subcutaneous toxicity was significantly
associated only with a lower value of DHI (0.77 vs.
0.73; p = 0.02). To further explore factors that might
contribute to the risk of fat necrosis (symptomatic
or asymptomatic), a separate analysis showed that
only dose hotspots as reflected in V150 and V200
were significantly associated with elevated risk. It
is interesting that while DHI proved to be a very
strong indicator of late skin toxicity and late subcutaneous toxicity, its use in balloon brachytherapy
completely disappeared. A reason is probably the
fact that most balloons can only achieve a DHI of
about 0.7, and the type of dose inhomogeneity in
the target tissue around a balloon is very different
from the one found in an interstitial implant. Below
are listed (for comparison) the NSABP B-39/
RTOG 0413 guidelines for target and normal tissue constraints [16]:
Treatment
technique
Interstitial
brachytherapy
Determination
factors
Dose
homogeneity
Skin
Ipsilateral
breast
Target
Dose constraints
DHI 0.75
DHI = (1 V150 %/
V100 %)
V150 % 70 cm3
V200 % 20 cm3
Skin Dmax <100 %
V50 % 60 %
>90 % of the
prescription dose
covers >90 % of the
PTV_EVAL
Treatment
technique
MammoSite
Determination
factors
Tissueballoon
conformance
air/
PTV_EVAL
Balloon
symmetry
Minimum
balloon
surfaceskin
distance
Ipsilateral
breast
Target
Dose constraints
Volume of trapped
<10 %
Deviation of
<2 mm from
expected
dimensions
Ideal: 7 mm
Acceptable:
57 mm if Dmax to
skin <145 %
V150 % 50 cm3
V200 % 10 cm3
V50 % <60 %
>90 % of the
prescription dose
covers >90 % of the
PTV_EVAL (after
accounting for
volume of trapped
air)
In later trials (e.g., the multi-institutional

phase IV Contura registry trial), the coverage
was increased to V95 95 %, while the max skin
dose was decreased to 125 % PD, and the max
dose to the proximal rib, previously unconstrained,
was set to no more than 145 %. In a comparison
between multi-catheter implants, Contura
multi-lumen balloon, and MammoSite single
lumen [30], the multi-catheter implants were
found to have the lowest skin and chest wall dose,
but between the two balloons, Contura was
found to have the lowest skin and rib dose: 82 %
PD and 82 %, respectively, vs. 94 % PD and
105 % for MammoSite. A recent study of
patterns of failure, patient selection, and
dosimetric correlates for late toxicity after APBI
using MammoSite balloon brachytherapy [31]
established an even lower limit for max skin
dose, skin dose >100 % significantly predicted
for the development of telangiectasia (50 % vs.
14 %, p < .0001), rediscovering the initial constraint set for multi-catheter implants. Despite
reports on late chest wall toxicity after
MammoSite breast brachytherapy [31] describing fractures occurred in ribs with V37 and V44
D.A. Todor
56
Gy, no clear thresholds were detected. In the

first analysis of the American Society of Breast
Surgeons MammoSite breast brachytherapy
registry trial [32], excellent results were noted
which compared favorably with other forms of
APBI with similar follow-up. The toxicity rates
with single-lumen brachytherapy-based APBI
were low with fewer than 10 % of patients developing infections, 13 % symptomatic seromas,
and 2.5 % fat necrosis. These numbers are comparable with WBI outcomes.
One interesting issue is the dose estimation for
OARs, most notably, skin and chest wall/ ribs. It
is the current practice to measure the maximum
dose to the surface of the skin and the maximum
dose to the proximal rib. The obvious question is
whether this is the best thing to do and whether it
is reproducible and/or accurate.
In a study of the pathogenesis of late radiationrelated fibrosis, the issue how to most
meaningfully estimate skin dose was raised:
Although subcutaneous radiation induced fibrosis
is probably the most common manifestation of
radiation injury, the exact depth in the skin most
responsible for the fibrotic process is unclear.
Bentzen et al proposed range of 3.35.5 mm as
acceptable reference points for subcutaneous
fibrosis in the breast, with the best estimate at a
depth of 4.1 mm. Unless consistency in
describing dose and measuring outcome is used,
we will remain at a disadvantage in predicting the
true incidence and dose response of RIF. [33]
How is this relevant for balloon brachytherapy

and why do we estimate the surface dose as
opposed to dose at a depth? The choice of depth
itself is only an issue if the dose to surface is not
correlated (uniquely determined) by dose to some
arbitrary depth (say 0.4 or 0.5 cm). In the case of
a balloon like MammoSite, where the source
can only be placed along the central lumen, dose
to the surface is likely in a fixed relationship (in a
first approximation, not taking into account the
lack of scatter that TG-43 does not take into
account) with dose to depth. Therefore, whether
reporting dose to surface (as we do now) or dose
to a meaningful depth (say, 0.41 cm) would
likely not change any clinical correlation between
dose to skin and toxicity. In the case of an
interstitial implant or even a multi-lumen balloon,
the number of dwell positions and their variable

position would make it such that the dose to the
surface would not be in a unique relationship
with dose at depth but would be case dependent.
Clinical correlations with dose will likely be
perturbed depending on the choice of depth for
reporting dose to skin.
Dose limits to these structures have evolved in
time, similar with definitions of PTV. In the
interstitial implants, as Edmundson describes
the skin dose is typically less than half the
prescribed dose, and no skin response is usually
seen. High local skin doses may result in small
areas of moist desquamation and perhaps an
excess of telangiectasia [17]. In NSABP B-39
the skin dose for interstitial implants is established to 100 % PD [16]. For the MammoSite
device, however, the maximum dose to skin is
coupled to the distance from the balloon to skin
surface. As the prescription is ideally delivered at
1 cm from the balloon surface, the constraint that
worked for interstitial implants would have been
met every time the balloon-to-skin surface distance would have been 1 cm or more. Since usage
of the balloon was also envisioned for shorter distances, a higher limit for skin dose was placed,
namely, 145 % PD. This is approximately the
equivalent of a 4 cm diameter balloon placed
0.5 cm from the skin surface. A larger balloon
would slightly improve things (e.g., a 5 cm diameter balloon at 5 mm from skin would only produce 136 % PD on the skin surface). There are
multiple publications reporting on dose limits for
OAR based on clinical outcome, and these publications emphasize the initial knowledge that a
skin dose of 100 % or less is safe. While initially
no dose constraint for ribs was declared in the
NSABP-B39, studies on rib fractures and chest
wall pain lead to the conclusion that there is a
safe limit and it is likely around 125 %
PD. Brashears et al. hypothesized volumes
receiving 37 and 44 Gy might be important, but
they concluded that given the possibility of a history of osteoporosis or exposure to adjuvant chemotherapy As long-term toxicity data accrue
from APBI series, the traditional models for estimating the biologic equivalent dose may benefit
from refinements that specifically address the
unique radiobiologic and physical properties

intrinsic to high-dose-rate brachytherapy for
breast conservation therapy [31].
1.9
Dose Calculation Formalism:

Effects of Contrast and Air
In 1995, the American Association of Physicists

in Medicine (AAPM) Task Group No. 43
published a clinical protocol on dosimetry for
interstitial brachytherapy sources, known as the
TG-43 formalism, and provided reference
dosimetry datasets for commercially available
192
Ir, 125I, and 103Pd sources.
While AAPM has reviewed and published
reference-quality dosimetry datasets for lowenergy brachytherapy sources in a number of
reports (TG-43, TG-43 U1, and TG-43 U1S1), no
similar effort has been attempted by AAPM or
the European Society for Radiotherapy and
Oncology (ESTRO) for high-energy sources. To
fill this void, the AAPM Brachytherapy
Subcommittee (BTSC) formed the High Energy
Brachytherapy Source Dosimetry (HEBD)
working group to focus on photon-emitting
brachytherapy sources with average energy
higher than 50 keV. The report [34] reviewed
published dosimetry for commonly used highenergy 192Ir, 137Cs, and 60Co sources, critically
reviewed the TG-43 U1 formalism, and developed
a complete consensus dataset to support clinical
planning for each source model.
New advances of dose calculation algorithms
using
sophisticated
model-based
dose
calculations (MBDC) have been recently
introduced for brachytherapy treatment planning
systems (TPS). While TG-43 models a single
source in an effectively infinite water phantom,
MBDC models sources, applicators, patient
heterogeneities, interfaces, and boundaries.
The two commercially available systems are
the BrachyVision Acuros (BV-Acuros) (Varian,
Palo Alto, CA) and the Oncentra Advanced
Collapsed Cone Engine (ACE) (Elekta,
Netherlands) MBDCs. BV-Acuros is a grid-based
Boltzmann solver (GBBS) that deterministically
solves the linear Boltzmann transport equation.
57
Oncentra ACE is a collapsed cone convolution

(CCC) algorithm which has been developed
specifically for performing dose calculations for
brachytherapy.
AAPM issued a report of a Task Group 186
[35] on the topic of model-based calculation
formalism beyond TG-43. In conclusion, it was
stated that it is important to acknowledge that
the bulk of clinical brachytherapy dosimetry
experience is with radiation transport and energy
deposition in water, with dose to water reported
(as calculated under the TG-43 approach). Hence,
for the time being the recommendation that
TG-43 calculations be performed in parallel with
model-based dose calculations is crucial. Only in
this way will the radiation therapy community
become familiar with dose differences, including
the impact on prescription dose and doses to
points, organs and regions of interest.
For breast irradiation with 192Ir, the most
important factor impacting TG-43 dose
calculation is the lack of complete scatter around
the implant, leading to an overestimate of the
skin dose (and to a smaller extent, target
coverage). The magnitude of this overestimation
was addressed by a number of investigators [36,
37] using multiple methods (TLD measurements,
Monte Carlo simulations, etc.). The effects were
found to be dependent on the balloon diameter,
with up to 9.8 % for a 4 cm balloon and 13.2 %
for a 6 cm balloon with no tissue beyond the
prescription distance at the breastskin interface.
Smaller magnitude effects were noted on the
breastlung interface, with 6.79.6 % differences
for the small and large balloon diameters,
respectively.
Also studied intensively were the effects of
contrast in the balloons and that of air pockets.
While mixing radiopaque iodine-based contrast
with water or saline helps visualizing the balloon
contour, an increased absorption and attenuation
can lead to a dose reduction if only a TG-43
calculation is performed (as opposed to a
heterogeneity corrected calculation). In a study
[37], concentrations ranging from 5 to 25 % by
volume of iodine-based radiopaque solution were
simulated in balloons with diameters between 4
and 6 cm. The dose rate reduction at the typical
D.A. Todor
58
prescription line of 1 cm from the balloon surface

ranged from 0.8 % for the smallest balloon
diameter and contrast concentration to a
maximum of 5.7 % for the largest balloon
diameter and contrast concentration, relative to a
water-filled balloon. Limiting the contrast
concentration to 10 % would insure less than 3 %
reduction in the prescription dose, regardless of
balloon diameter. In terms of air pockets effects,
the dose near the balloon surface may be
increased by 0.5 %/cm3 of air [38]. Monte Carlo
simulation suggests that the interface effect
(enhanced dose near surface) is primarily due to
Compton electrons of short range (<0.05 cm).
Some of the issues regarding inhomogeneity
and boundaries are exacerbated by the use of
low-energy source like Xoft Axxent. In a study
comparing TG-186-based calculations with
TG-43 for balloon applicators [39], based on a
prescription dose of 34 Gy, the average D90 to
PTV was reduced by between ~4 % and ~40 %,
depending on the scoring method (dose to water
(Dw, m) and dose to medium (Dm, m)), compared to
the TG-43 result. Max skin dose was also reduced
by 1015 % due to the absence of backscatter not
accounted for in TG-43. The final conclusion of
the study was that Tissue heterogeneities,
applicator, and patient geometries demonstrate
the need for a more robust dose calculation
method for low energy brachytherapy sources.
1.10
Uncertainties in Planning
and Delivery
All balloons, independent on whether they use

one lumen or multi-lumens, have the theoretical
possibility to rotate once implanted in a patient.
Of course, rotation of a balloon with a perfectly
central lumen would not produce any changes in
dose, as dose distributions with cylindrical
symmetry are invariant to rotation around the
central axis. It is interesting to note that while
the balloon rotation became a real issue with the
development of the multi-lumen balloon, NSABP
B-39 acknowledged the fact that the single-lumen
MammoSite balloon can be asymmetrical and
placed a limit (0.2 cm) to the asymmetry but
without acknowledging the potential effect of an

asymmetrical balloon rotating during treatment
(between fractions). The Contura multi-lumen
balloon has a black line, an orientation line, on
the shaft of the applicator to identify the position
of Lumen #1. If at the time of the CT the patient
had a skin mark drawn to align with the orientation
line, a photo is taken and subsequently verified
before each fraction, this should ensure an
accurate non-rotational position of the balloon. In
a study of sixteen patients in which the patients
underwent CT scans before each fraction, a
method was validated to accurately confirm the
orientation of the Contura multi-lumen balloon
catheter before each fraction, and they determined
if any residual device rotation remains after
adjustment [40]. Using the external alignment of
a skin mark with the orientation line was deemed
an accurate and reliable method to align the
balloon before treatment and no significant
internal device rotation (<0.02 cm) occurred.
Dosimetric impact due to MLB rotation has
been recently studied by Kim et al. [41]. For a
plan with both of skin and rib distance less than
0.7 cm, the maximum degradation on D95 of the
PTV_EVAL was about 6.5 % when there was a
120 rotation error. They found that in a clinical
situation, which had a rotation error smaller than
10, the degradation on D95 and D90 of the
PTV_EVAL were less than 1 % and the deviation
of the skin and rib dose were less than 2.5 % of
the prescription dose.
In the process of planning and delivery, there
are sources of error and uncertainty. Among them
are the size and shape of balloon, the seroma
volume, the delineation and the length
measurement of the applicators, the positional
accuracy of planned vs. delivered dwell positions,
etc. Some of these were examined in a study on
42 CT images scanned from seven patients [42].
The original plans (as group A) had a mean value
of 96.8 % on V95 of the PTV_EVAL. Another
group (B) was created in which that the mean
value of the V95 was relaxed to 90.4 %. A
geometrical uncertainty with a mean deviation of
0.27 cm per root of sum of square caused the
degradations of V90 and V95 by mean values of
1.0 % and 1.2 %, respectively. A systematic error
of 0.3 and 0.4 cm would degrade both of V90 and

V95 by 4 % and 6 %, respectively. The
degradations on target coverage of the plans in
group A were statistically the same as those in
group B, concluding that Overall, APBI
treatments with MLB based brachytherapy are
precise from day to day.
Conclusions
Accelerated partial breast irradiation is a new

technology that provides faster, more convenient treatment after breast conservation surgery. Of all the APBI modalities, balloon
brachytherapy is probably the technique at the
confluence of an important number of desirable features. Given the single entry catheter
as opposed to multiple catheters in interstitial
implants, it is probably the easiest for patients
to tolerate. Relying on a balloon surface as a
GTV surrogate instead of the delineation of an
uncertain lumpectomy cavity, together with
the use of library plans, makes planning an
easy task. While our dose computation formalisms are evolving, we do have a reasonable good understanding of the dosimetric
factors which play a role in good outcomes of
the treatment. Long-term follow-up and
guidelines like those outlined in RTOG 0413/
NSABP B-39 national phase III trial will
hopefully demonstrate the long-term effectiveness and safety of this method for selected
patients with early breast cancer.
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Part I
Disease Site Specic Topics
Ocular Brachytherapy
Stephen Karlovits and Thierry Verstraeten
Abstract
Episcleral plaque brachytherapy (EPB) has been utilized since the first
half of the last century to treat intraocular tumors [1]. The two most common indications for EPB are ocular/choroidal melanoma (CM) and retinoblastoma. Although the techniques are similar, the focus of this chapter
will be on the treatment of CM.
Introduction
CM is the most common primary malignancy of

the globe but its incidence is only 4.3 cases/
million in the USA [2]. Local control is paramount
as failure to achieve this goal results in both local
(vision loss, pain) and systemic (liver, lung, bone
metastasis) consequences including death. In the
1960s enucleation with subsequent histopathology
demonstrated close to 20 % of erroneous diagnosis, and as the observational skills of ophthalmologists improved, that rate fell to less than 5 % by
the mid-1970s [3]. Prior to the 1980s, the
S. Karlovits, MD (*)
Allegheny Health Network Cancer Institute,
Allegheny General Hospital, Pittsburgh, PA, USA
Radiation Oncology, Temple University
School of Medicine, Pittsburgh, PA, USA
T. Verstraeten, MD
Department of Ophthalmology, Allegheny
Ophthalmic and Orbital Associates, Drexel University
College of Medicine, Pittsburgh, PA, USA
treatment of choice was enucleation (eye

removal) with the associated major downside of
ipsilateral vision loss. Along with improving
skills, the introduction of fine needle aspiration
biopsy in the mid-1980s improved the accuracy
of diagnosis [4].
Historically EPB was first introduced by
Stallard in England in the 1950s using cobalt
60 [5]. This technique could offer the possibility of both organ and resultant vision preservation while controlling or eradicating the tumor.
Subsequently, different isotopes were tried,
including iridium 192, ruthenium 106, iodine
125, and later palladium 103 [6]. Episcleral
brachytherapy using various radionuclides
has been performed in the treatment of CM at
numerous institutions across the globe for years.
However, the only randomized study reflecting
class 1 evidence for effectiveness compared to
enucleation is the Medium Tumor Collaborative
Ocular Melanoma Study (COMS) [7, 8]. This
multi-institutional trial enrolled more than 1300
patients with medium-sized CM, and patients

DOI 10.1007/978-3-319-26791-3_6
63
S. Karlovits and T. Verstraeten
64
were randomized to either enucleation or 125I

EPB. At 12 years mean follow-up, there was no
survival difference including death from histopathologically confirmed melanoma metastases
[8]. Eighty-seven percent of patients treated with
EPB retained their eye at 5 years with 43 % of
the treated eyes demonstrating visual acuity of
20/200 or worse at 3 years [9, 10].
Prior to 2002, the main standardized clinical
guidelines were those as set forth in the COMS
study, but these were based on 125I. However, many
other sources in addition to 125I have been used and
are in use with EPB globally including 60Co, 106Ru
(Europe), 103Pd, 90Sr, and 131Cs [5, 1120]. The
American Brachytherapy Society (ABS) therefore
convened an EPB consensus conference in 2002
focusing on CM and then again in 2013 focusing
on both CM and retinoblastoma and published
guidelines [21, 22]. In addition, the American
Association of Physicists in Medicine (AAPM)
Task Group (TG) 129 medical physics guidelines
were published in two reports 2011 and 2012
[23, 24]. The first compared the dosimetry of the
two most common radionuclides in use in North
America (103Pd and 125I). The second focused on
ideal dose calculation, radiation safety, and quality
assurance [22].
1.1
Workup and Staging
Since 2002, the ABS has recommended that

EPB be performed only in specialized medical
centers as both the complexity of the workup
and ultimate treatment require an experienced
multidisciplinary team [21]. Recommended initial ABS workup includes full ophthalmic exam
including intraocular pressure and visual acuity
as well as ophthalmoscopy, fundus photography,
and ultrasound [25, 26]. Clinical diagnosis is
adequate for treatment and histopathologic confirmation is optional [22]. Increasing benefits of
obtaining tissue prior or during the application of
EPB include the ability to identify the molecular genetics of the tumor with prognostic value
and quantification of metastasis risk [27]. In
the mid-1990s, the discovery of a chromosome
3 monosomy mutation in enucleated globes led

to the observation of a 50 % risk of metastasis
by 3 years compared to eyes not affected by the
mutation [28]. Once the diagnosis is established,
a metastatic workup should be performed including complete physical exam, liver function studies, and chest X-ray. Computed axial tomography
(CT) of the chest and abdomen is performed if
indicated [21]. The ABS Ophthalmic Oncology
Task Force (ABS-OOTF) [22] has adopted the
seventh edition American Joint Committee on
Cancer (AJCC) eye cancer staging system for
uveal melanoma [22, 29].
1.2
Case Selection
As stated in their 2013 report, the ABS exclusion

criteria for EPB have become more limited,
basically now including only gross extraocular
extension (T4e or >5 cm), basal diameters that
exceed brachytherapy limits, blind painful eye,
and no light perception [22]. Patients with tumors
near the fovea or optic nerve need to be counseled
on potential brachytherapy morbidity such as
blindness [3032]. Visual outcomes generally
improve as the distance increases, between the
plaque and macula or optic nerve, and as the
tumor volume decreases [33]. Recent advances
include intravitreal injection of triamcinolone
and anti-vascular endothelial growth factor (antiVEGF) agents to limit the incidence of radiation
retinopathy and optic neuropathy [34, 35].
1.3
Treatment Planning
Required information from the ophthalmologist

includes eye laterality, tumor AJCC stage, tumor
size (basal diameter and height) confirmed by
ultrasound, and a detailed fundus diagram [29,
36]. The fundus diagram should include tumor
location, tumor measurements, as well as the
distances from the tumor to the fovea, optic
nerve, lens, and opposite eye [22]. Ideally, this
information is then transferred from the fundus
diagram to a computerized treatment planning
program per AAPM/ABS TG 129 [23, 24]. The

radionuclide of choice dosimetric information is
inputted, and then tumor dosing as well as dose to
critical structures at risk such as the macula, optic
disk, and lacrimal gland can then be calculated
per COMS and TG 129 [23, 24].
Tumor diameters must not be greater than the
planning target volumes or the diameter of the
plaque to avoid a geographic miss [22]. In accordance with COMS, the ABS-OOTF recommends
the tumor apex (point of maximal thickness) as
the prescription point. Also, the prescription isodose line should encompass the entire tumor volume to maximize local control. Depending upon
the radionuclide chosen, the total dose to the apex
may vary between 70 and 100 Gy. Additionally,
the dose rate should not be less than the equivalent
COMS standard of 0.60 Gy/h for 125I [22] At our
institution, we follow the COMS guidelines and
use 125I plaques with a 0.2 cm margin around the
basal diameter of the tumor and prescribe 85 Gy
to the tumor apex with a mandated minimum of
85 Gy to 5 intraocular millimeter thickness.
1.4
65
Fig. 1 External photograph of gold COMS plaque sewn

to the sclera after localization
then remains in place for the preplanned duration calculated to deliver the appropriate dose
at depth and then removed under local and/or
general anesthesia and any relocated muscles are
reattached. The removal time, seed count, and
radiation survey (patient, operating room, and
if applicable patients hospital room) are then
recorded in the radiation record [21, 22].
Surgery
First and foremost the ABS-OOTF recommends that these procedures be performed by
a team comprised of ophthalmic oncologists,
radiation oncologists, and medical physicists in
experienced subspecialty centers. Actual placement of the eye plaque is done under local and/
or general anesthesia. The tumor first needs to
be localized by the surgeon. In most cases, the
scleral shadow of the tumor base is identified by
trans-pupillary or transocular illumination and
marked. Measurements are then taken to confirm
that the fabricated eye plaque is adequate to cover
the tumor base and planning margin. Sutures are
placed into the sclera with or without the aid of
a dummy plaque and the eye plaque is affixed
(Fig. 1). If an ocular muscle encroaches on the
site, thereby preventing proper EPB placement,
it is temporarily relocated. Insertion time is
recorded into the radiation record and a lead eye
patch is placed over the affected eye. The EPB
1.5
Follow-Up
In general, most patients are then followed every

36 months with a complete physical and ophthalmic exam to assess for tumor response/recurrence, radiation-related morbidity, and metastatic
disease. The ABS-OOTF recommends (with
level I consensus) that periodic hepatic imaging
be performed to detect subsequent metastases to
allow for more prompt systemic management
[22]. At our institution, the patient is discharged
after the initial 4-day hospital stay and is followed on an outpatient basis at 1 week, 1 month,
3 months, and then every 6 months for 5 years.
Serial fundus photography (Figs. 2, 3, and 4) and
ultrasound A and B scans are performed to monitor the treatment response. Longer follow-up is
recommended as we have seen liver metastasis
occur at 7 years post brachytherapy with local
ocular tumor control.
66
Fig. 2 Fundus color photograph (montage) of the left eye

in a 67-year-old white female showing a sessile tumor of
the nasal periphery measuring 12 mm diameter and 6 mm
elevation. Vision is 20/25
Fig. 3 Same eye 18 months after I125 brachytherapy.

Note radiation retinopathy over tumor surface with
hemorrhaging and exudation. No additional treatment
performed. Vision is 20/25
1.6
Clinical Outcomes
Clinical outcomes are difficult to quantify due

to the variability of technique, skill level, treatment planning, isotopes used, and tumor-related
characteristics (mainly location and size)
between institutions and continents. The only
class I evidence pertains to medium-sized CM
treated with 125I EPB versus enucleation with
results published in multiple outcome-specific
reports by the COMS. As published in COMS
Report No. 16, baseline visual acuity in the
affected eye was 20/32 (median) with 70 % at
least 20/40 and 10 % at best, 20/200. Threeyear visual acuity results were 20/125 (median),
34 % and 45 %, respectively. Visual decline
was progressive post implant with those with
baseline affected eye visual acuity greater than
Fig. 4 Same eye 30 months after treatment. Note

disappearance of vascular changes and excellent tumor
control (measurements: 10 mm diameter and 3 mm
elevation)
20/200 worsening to (at best) 20/200 at a rate of

17 % by year 1 and 43 % by year 3. Other than
baseline visual acuity, the factors most strongly
associated with a posttreatment visual acuity
of 20/200 or worse were greater initial apical
tumor height and shorter distance between the
tumor and foveal avascular zone (FAZ) [10]. In
those patients randomized to eye preservation,
the 5-year risk of tumor recurrence was 10.3 %
and the 5-year need for salvage enucleation was
12.5 % per COMS Report No 19. The most
common reason for enucleation within the first
3 years was tumor recurrence. After 3 years,
pain was the most common reason. Mirroring
the risk factors for visual decline, common risk
factors for both recurrence and enucleation
were greater tumor thickness and shorter distance between the tumor and FAZ [9]. Overall
12-year mortality rates and prognostic factors were published in COMS Report No. 28.
Cumulative all-cause 5-year mortality was 19 %
overall, and the 12-year mortality in the brachytherapy arm versus enucleation arms was 43 %
versus 41 %, respectively. Five- and 12-year
risk of death with histopathologically confirmed
melanoma metastasis was 10 % versus 11 %
and 21 % versus 17 %, respectively [8]. COMS
Report No. 26 included both the medium and
large CM COMS trials and showed the majority
of metastatic disease occurred with the first 5
years of follow-up, with the liver being the most
common location (89 %). The overall 5- and
10-year metastatic rates were 25 % and 35 %,
67
respectively. The death rate after diagnosis of

metastatic disease was 80 % at 1 year with few
long-term survivors [37].
1.7
Complications
Both acute and late complications are related to

treatment and tumor-related factors such as total
dose, dose rate, treatment volume, and location
[38, 39]. Late complications predominate, and
the incidence increases over time with the most
common being radiation retinopathy [21, 22].
The onset of retinopathy is rare in the first year
but increases between 12 and 18 months following brachytherapy. The proximity of the tumor to
the macula or posterior pole increases the risk.
Peripheral retinal vascular leakage with exudation and hemorrhage is often seen over and
around the perimeter of larger or thicker tumors
(Fig. 3). Often these complications can be controlled by the administration of intravitreal steroids, anti-VEGF agents, and the applications of
laser photocoagulation. The development of a
cataract is often expected for tumor located anterior to the equator of the globe and in the ciliary
body. Overall the incidence of cataract formation
was 68 % within the first 5 years in COMS
Report No. 27 [40]. It is preferable to delay the
performance of cataract surgery or other penetrating surgeries like glaucoma surgery or vitrectomy surgery until tumor regression is observed
(12 years post procedure). This is advisable to
lower the risk of extraocular dissemination of
malignant cells. COMS Report No. 30 showed a
5-year risk of optic neuropathy of 27.4 % with
125
I EPB with major risk factors being diabetes
and proximity to the optic nerve, FAZ, and fovea
[41]. A late complication seen in about 5 % of
the eyes is the development of scleral necrosis
with the appearance of progressive extraocular
dark pigmentation (Fig. 5). It has been our experience and that of others (Shields personal communication) that these can often be managed by
conservative monitoring as these visible cells are
no longer malignant. Rarely though, a scleral
patch graft or possibly enucleation may have to
be performed.
Fig. 5 External photograph of the right eye in an 88-yearold white female 5 years after brachytherapy. The initial
tumor measured 14 mm diameter and 8 mm elevation in
the temporal equatorial region. Note dark pigmentation
with 2 mm elevation and the absence of sclera. This is not
representing extrascleral tumor growth. Internally the
tumor is regressed and measures 2 mm elevation. The
vision is 20/80 and the patient is comfortable
Conclusions
This chapter represents our multidisciplinary

approach to EPB for choroidal melanomas,
and the reader is encouraged to refer to the
ABS-OOTF and AAPM/ABS TG 43 and TG
129 guidelines for expanded information on
specific clinical scenarios, technical issues,
and quality assurance.
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Head and Neck Brachytherapy:

A Description of Methods
and a Summary of Results
D. Jeffrey Demanes
Abstract
Brachytherapy applications for head and neck are diverse and sometimes
complicated. Knowledge of anatomy and the ability to perform complex
procedures are basic prerequisites. This chapter addresses most head and
neck brachytherapy other than radionuclide treatment of thyroid cancer
and eye plaques for melanoma. The literature is comprehensively reviewed,
but it is not exhaustive. It is recommended that the reader also consult
Modern Brachytherapy [1], GEC-ESTRO Handbook of Brachytherapy
[2], Head and Neck Cancer [3], and Brachytherapy: Applications and
Techniques [4].
Introduction
1.1
History of Technical
Developments
Head and neck brachytherapy began with

radium-226 applications to the skin and lip.
Radiation dose was described as the amount of
radium and the duration of the application
(milligram-hours). Treatment of deeper head and
neck lesions required development, mostly by
surgeons, of interstitial techniques. As the specialty evolved, radiologists became more adept
D.J. Demanes, MD, FACRO, FACR, FASTRO
Professor, Division of Brachytherapy, Department of
Radiation Oncology, , University of California
Los Angeles (UCLA), Los Angeles, CA, USA
e-mail: [email protected];
[email protected]
and proficient at interstitial insertion of permanent radon seeds or temporary radium needles.
Such applications were, by necessity, done
quickly to limit radiation exposure to medical
personnel.
In the 19501960s, with the advent of cyclotrons, scientists such as William G Meyer developed man-made radioactive sources, which could
be delivered through small needles and catheters.
Ulrich Henschke in the United States and Bernard
Pierquin in France pioneered their clinical use.
As a result, permanent gold-198 and iodine-125
seeds replaced radon seeds, and iridium-192
seeds replaced radium-226 needles for head and
neck brachytherapy [5].
Permanent seeds have sufficiently low energy
to allow safe handling in the operating room and
tissue attenuation such that patients can be safely
discharged home after the procedure. The radia-

DOI 10.1007/978-3-319-26791-3_7
71
72
tion dose is dependent upon the source activity

and the geometry of the implant. The duration of
treatment varies according to the radionuclide
half-life: iodine-125 (59 days), palladium-103
(17 days), and cesium-131 (9.7 days) as the
sources decay to become essentially inert.
Permanent seeds are convenient because they are
inserted in a single procedure, but their distribution is often difficult to control, especially at
mucosal surfaces or in mobile soft tissue. Once
inserted, seeds cannot be purposefully moved or
adjusted.
Iridium-192 became the source of choice for
temporary interstitial implants. It emits a highenergy photon, so treatment must be delivered in
controlled areas for radiation safety. The interstitial implants are performed by the insertion of a
scaffolding of hollow applicator tubes without
hurry or concern of radiation exposure. The iridium-192 is later temporarily inserted into catheters for treatment delivery (i.e., afterloaded). The
sources may be inserted by hand or by a robotic
delivery device. Once the sources have been
removed, there is no residual radiation exposure.
Iridium-192 is supplied for manual loading as
low-activity seeds embedded at 0.5 cm intervals
along the length of nylon ribbons (which looks
like a monofilament fishing line) or as a component of a continuous wire. More commonly now,
it is inserted robotically as a single very highintensity radiation source attached to the end of a
fine cable (remote afterloading).
Temporary brachytherapy is classified by the
rate at which the dose is delivered. Low dose rate
(LDR) is defined as <2 Gy/h. It involves the
insertion of low-intensity iridium-192 seeds in
ribbons, by hand, into the afterloading catheters.
The dose is determined by multiplying the dose
rate by the duration of treatment (typically
13 days). The problems with manual source
loading are radiation exposure to medical personnel, patient isolation, and restrictions on nursing
care.
High dose rate (HDR) is defined as >12 Gy/h
(medium dose rate is 212 Gy/h). It uses remote
afterloading devices, which are the necessary and
logical solution to the problem of radiation exposure to medical personnel. Engineers, all over the
D.J. Demanes
world, began to develop reliable robotic afterloading devices in the 1980s. The number and
size of the doses given per day classify the application as HDR or pulsed dose rate (PDR). High
dose rate typically gives 36 Gy (up to about
20 Gy) per session. The dose is often given twice
(occasionally three times) per day with 46 h
intervals between treatments. There are significant radiobiological implications to these large
doses per fraction in that the biological effect
increases exponentially with dose. PDR mimics
the radiobiology of continuous LDR by giving
small doses of radiation hourly on either 12 or 24
hour schedule. A detailed history of afterloading
brachytherapy has been published [6].
Interstitial implants are the primary method
used for head and neck brachytherapy. Dosimetry
is as important as total dose and dose rate. As
brachytherapy became more widely used in the
middle of the twentieth century, various systems
of dosimetry evolved. In the 19301940s,
Quimby (New York) developed a uniform loading system for brachytherapy sources which
resulted in high doses in the center of the implant
where less sensitive hypoxic cells are located
[79]. Patterson-Parker (Manchester), on the
other hand, preferred a more uniform distribution
based upon geometric arrangements of sources in
planes or volumes [1012]. In France in the
1970s, Pierquin et al. developed rules for interstitial dosimetry to describe mean doses at locations
between planes of sources and the minimal
peripheral dose concepts (i.e., the minimum dose
that encompasses the target) [13]. All of these
systems have given way to computer-based treatment planning and dosimetry [14].
Dosimetry was initially based upon twodimensional imaging that gave isodose depictions
and point doses without precise anatomic correlations. However, the advancement of 3D imaging
by the third quarter of the twentieth century provided anatomic data in which tumor volumes and
critical structures (organs at risk (OAR) such as
the eye, spinal cord, and mandible) could be accurately incorporated into dosimetry calculations.
Dose volume histograms (DVH) provided virtual
image reconstructions, standard target volume isodose descriptions (V100, V150, V200), and doses
Head and Neck Brachytherapy: A Description of Methods and a Summary of Results
to specified target volumes (D90 or D100).

Similarly, normal tissue doses were reported in
terms of doses to specified volumes of normal
tissue such as 0.1 cc (surrogate for maximum
dose), 1 cc, and 2 cc (D0.1 cc, D1cc, and D2cc).
Finally, inverse treatment planning became
available in brachytherapy where target dose specifications and normal tissue dose constraints could
be entered and calculated through an iterative process to find optimal dosimetry solutions [15].
Indications and Uses

of Brachytherapy for Head
and Neck Cancer
2.1
Pretreatment Workup of Head

and Neck Cancer
The staging and workup of head and neck cancer

depends upon the primary site and type of cancer.
A complete general patient evaluation and a careful head and neck examination are the first steps.
In an office, fiberoptic nasopharyngoscopy or
direct laryngoscopy under anesthesia is typically
needed for complete examination of the mucosa
and to assess the airway. Pathologic confirmation
of disease is a prerequisite to radiation therapy.
Biopsy of the mucosal lesion confirms the primary, and a fine-needle aspiration or neck dissection is usually diagnostic of regional spread.
Imaging often includes a high-quality MRI
(assuming no contraindications to the study) to
determine the soft tissue and bone marrow components of disease, a CT with contrast to assess
cortical bone invasion, and a PET-CT to identify
local functional activity and distant metastasis.
Dental evaluation and psychosocial assessments
are also basic components of the workup.
2.2
General Considerations
Radiation therapy is an effective treatment for

head and neck cancer, but it has acute and chronic
side effects. Mucositis, salivary dysfunction, and
taste impairment are expected, and there is a
potential for deeper injuries to mucosa, glandular
73
tissue, muscle, neurovascular structures, and

bone. The long-term clinical consequences may
include impairments of speech and swallowing,
tooth decay, soft tissue or bone necrosis, neuropathy, and vascular disease. Radiation therapy also
negatively affects surgical wound healing and
exacerbates postoperative fibrosis. There is a
small risk of radiation-induced second malignancy (typically sarcoma), although such cancer
is rare compared to recurrent cancer and second
mucosal primaries. All of these radiation effects
are radiation dose and dose distribution
dependent.
Brachytherapy delivers a high radiation dose
to a localized target without having to traverse
normal tissue to reach the target. It thus has a
dosimetric advantage for accessible and sufficiently well-defined targets. Brachytherapy
requires anesthesia and thus carries some procedural risks. However, there are no major wounds
to heal, and the anatomy, function, and appearance of the implanted structures are typically preserved. The outcomes with brachytherapy are
dependent on implant quality and proper case
management.
Brachytherapy may be used in virtually any
head and neck cancer, primary or recurrent,
where hollow catheters can be safely inserted.
The relative risks and benefits of surgery, external radiation with or without chemotherapy, and
brachytherapy should be considered for all
patients with head and neck cancer. Brachytherapy
may be an alternative or complementary to surgery. As an alternative, it avoids the morbidity
associated with tissue removal and reconstruction. Most experts agree that there are significant
advantages to surgery when disease invades bone
and it is preferred in certain tumors like salivary
gland cancers that are less responsive to radiation
than squamous cell carcinoma. Surgery also provides important pathological information about
the local and regional (when a neck dissection is
performed) extent of disease. Brachytherapy can
be complementary to surgery by extending treatment for close or positive pathological margins.
It can be done simultaneously with the surgery
where intraoperative exposure is useful, or it can
be done after surgery to allow wound healing and
D.J. Demanes
74
full evaluation of surgical pathology.

Postoperative brachytherapy might be selected
instead of EBRT for an oral cavity lesion, for
example, to reduce postoperative radiation side
effects when the treatment target is believed to be
localized and where lymph node irradiation is not
indicated.
Because of its physical characteristics, brachytherapy delivers relatively higher tumor doses and
lower doses to adjacent normal anatomy than
EBRT. As a result, it usually does not cause longterm symptomatic injury to salivary glands, taste
buds, pharyngeal musculature, or the carotid arteries. The decision to use brachytherapy alone or in
combination with EBRT primarily depends upon
the likelihood of regional spread of disease. When
used with EBRT, brachytherapy offers precise
delivery of the high doses needed to control gross
disease (at the primary site or in bulky lymph nodes)
while EBRT delivers more uniform doses needed
for control of microscopic lymphatic or perineural
disease. Therefore, brachytherapy offers the opportunity, with or without EBRT, to optimize the radiation distribution for organ preservation and to
maximize local disease control. Cosmetic results
with brachytherapy are typically good.
The connection of human papillomavirus
(HPV) to squamous cell carcinoma of the oropharynx has altered our understanding of the disease, and it has been found to have a better
prognosis than tumors associated with alcohol
and tobacco. This discovery has led to new treatment strategies of radiation dose de-intensification
[16]. It appears that the cure rates may not be
adversely affected by less treatment, and therefore the side effects could be diminished [17].
The reductions may be in dose, volume, or the
need for sensitizing chemotherapy. Since the
brachytherapy is intrinsically target volume and
dose specific, it should be considered as a form of
treatment with de-intensification to normal tissue
without sacrificing tumor dose for local control.
The chance for disease control, the functional
outcome, and the likelihood of major complications in head and neck cancer depend upon many
factors, including the kind of cancer, stage of disease, and comorbidity status. Treatment must be
offered in the context of the patients overall health,
smoking and alcohol history, human papillomavirus association (HPV/P16), and psychosocial circumstances. The relative risks and benefits of
surgery, radiation, or chemoradiation are often
debated, and it is not always possible to recommend one specific best treatment. Since there are
few direct comparative studies and even fewer controlled trials that incorporate brachytherapy, the
benefits of brachytherapy may not be fully recognized or made available to the patient. Ultimately,
the individual patient must decide which of the
various treatment alternatives to accept.
Brachytherapy Without
External Beam
3.1
Early Cancers of the Lip,

Buccal Mucosa, Nasal
Vestibule Oral Cavity
Brachytherapy can be administered as a sole

treatment (monotherapy) or in conjunction with
EBRT. Used alone, brachytherapy is typically
done as a single interstitial implant followed by
several days to a week of therapy [18].
Monotherapy causes little in the way of longterm xerostomia or decrease in taste function. By
way of intent, it is the radiotherapeutic equivalent
of a wide local excision without lymph node dissection. The use of brachytherapy alone reduces
the volume of normal tissue irradiated, and it
allows subsequent irradiation or surgery, if
needed. If successful, it provides disease control
with preservation of structure and function of the
affected site.
Treatment to the primary site alone is predicated upon the disease being localized (i.e., no
nodal metastasis); therefore, the indications
relate to lesion size, location, and histology.
Stage T1 or small T2, anterior (lip, nasal vestibule, and oral cavity), and well-differentiated
lesions without perineural (PNI) or lymphovascular invasion (LVI) are prime indications
because they are more likely to be localized than
large, posterior (pharyngeal), or poorly differentiated cancers. To achieve success, the curative
brachytherapy dose should fully encompass the
primary disease with a 11.5 cm margin in all

dimensions.
Properly selected lesions of the localized type
can be effectively managed with either wide local
excision or brachytherapy or by a combination of
excision and postoperative brachytherapy. There
is no consensus and few comparative studies to
determine whether surgery or brachytherapy is
more effective for early lesions or if they are
equivalent. The use of brachytherapy instead of
EBRT reduces the side effects (dry mouth and
taste impairment) and reduces the dose to surrounding soft tissue and the mandible. The decision to use surgery versus radiation may be
influenced by the lesion characteristics. For
example, exophytic growth patterns are well oxygenated and more responsive to radiation.
Endophytic or infiltrating lesions, which may be
ulcerated or necrotic, might be resected and
treated with postoperative brachytherapy or
external beam or both. The indications for postoperative brachytherapy include pathological
assessment of surgical margins, the pathological
extent of disease, the presence of LVI or PNI, and
any concerns by the surgeon that surgery alone is
insufficient.
Surgery is generally preferable to radiation
therapy for lesions involving bone because the
needed tumor doses are likely to exceed normal
tissue tolerance, and the combination of surgery
and radiation yields better outcomes. Once the
relatively thin gingival mucosa has given way, the
exposed bone is more prone to infection and
osteonecrosis, especially the mandible (body
more than ramus) with its limited blood supply.
Edentulous patients and those with healthy gums
are at less risk of mandibular necrosis than
patients with teeth or gingivitis. Brachytherapy
helps avoid injury to the mandible, if properly
administered, because lower doses are delivered
to the bone and salivary function is relatively preserved. Bone and teeth are impediments to the
placement of brachytherapy catheters. However,
in some cases when need arises, they can be successfully managed by wrapping around or attaching brachytherapy catheters to the surface of the
bone to treat lesions that are not too deep or
extensively erosive.
75
Neck dissection and elective nodal irradiation

are not necessarily routine measures for early
cancer of the lip or oral cavity cancer, but patients
with clinical or surgical-pathological evidence of
lymph node involvement are prime candidates
for neck irradiation. Selected cases with limited
adenopathy after neck dissection may not need
postoperative radiation therapy [19, 20]. Without
neck surgery, the decision to administer elective
nodal irradiation would depend upon the nature
and extent of the primary or imaging evidence
such as PET-CT to suggest the neck is involved.
Recurrence in the untreated neck can (often) be
successfully salvaged with a neck dissection and
postoperative EBRT, but salvage treatment is
typically more complicated and morbid than initial treatment [21, 22].
3.2
Cancer of the Oropharynx
Regional metastases are common in cancers of

the oropharynx. Consequently, management of
these tumors usually involves treatment of at-risk
lymph nodes with EBRT. As our ability to identify microscopic spread improves, local treatment
only and the benefits of reduced morbidity may
become feasible. In the meantime, highly selected
patients with T1N0, whose PET scans are negative, might be treated with brachytherapy alone
(monotherapy). Tonsil and soft palate lesions are
probably more suitable candidates for monotherapy than base of tongue primaries where it can be
difficult to determine the extent of the primary
lesion. Patients with oropharynx cancer who
decline surgery and external beam may be offered
brachytherapy.
3.3
Brachytherapy
with External Beam
EBRT is fundamental to comprehensive therapy

in diseases with a high rate of lymph node
involvement. Intensity-modulated radiation therapy (IMRT) with or without concomitant or neoadjuvant chemotherapy, when used without
brachytherapy, is usually given to about 70 Gy.
D.J. Demanes
76
Randomized clinical trials of EBRT alone versus

EBRT with chemotherapy favor combined therapy [23]. The morbidity of IMRT with chemotherapy, however, is greater than when radiation
is used alone. The acute side effects of chemoradiation commonly result in treatment breaks and
hospitalization. Reduction of late toxicity by
dose de-escalation can be achieved in HPV
(P16)-positive cases where there is a better prognosis [17]. Decreases in both acute and late toxicity can also be effectively achieved with
brachytherapy. When brachytherapy is used with
IMRT, the rationale is to take advantage of both
technologies to optimally deposit the dose in the
primary and nodal targets to limit the dose as
much as possible to pharyngeal muscles, salivary
tissue, and major blood vessels. There have been
no clinical trials to compare IMRT (or chemoradiation) versus IMRT with brachytherapy. It
would be valuable to study to what extent brachytherapy would enhance local tumor control or
reduce morbidity.
Chemotherapy should be discontinued before
brachytherapy to avoid metabolic perturbations
and blood count depressions that will complicate
the procedure. The primary benefit of chemotherapy is to enhance the effect of radiation on local
and regional disease. However, this goal might as
well be achieved with brachytherapy without
chemotherapy. Although it is not widely recognized, brachytherapy can be used to boost gross
adenopathy as well as the primary, and it simplifies the integration of EBRT and brachytherapy.
Lesions suitable for combined brachytherapy and
IMRT are large oral cavity lesions, cancers of the
pharynx, poorly differentiated cancers, and adenoid cystic carcinoma.
3.4
Locally Advanced Oral

Cavity Not Suitable
for Brachytherapy Alone
Brachytherapy is used as a boost to EBRT for

locally advanced or regionally disseminated cancers of the lip and oral cavity that are not suitable
for brachytherapy alone [18, 24]. These larger
lesions, particularly those with endophytic
growth, are more difficult to control, and there is

a greater likelihood of regional spread. Under
these circumstances, brachytherapy offers the
advantage over EBRT alone of localized dose
escalation with the potential for enhanced tumor
control and less dose to the mandible, salivary
glands, and taste buds. Surgical resection of the
lesion followed by brachytherapy and EBRT is a
common strategy for locally advanced disease
that may improve local control rates, but it is also
associated with more functional impairment of
the tongue. Indications for postoperative brachytherapy are LVI, PNI, positive or close margins,
or lymph node involvement [25]. There must be a
suitable interval and careful assessment for
wound healing to avoid disruption of free-flap
grafts. Chemotherapy may have a role in cases of
locally or regionally advanced cancers of the oral
cavity [26].
3.5
Oropharynx (Base of Tongue,

Tonsil, Soft Palate,
and Pharyngeal Wall)
Oropharynx cancer usually presents as adenopathy or as a locally advanced primary. The distinction between various subsites is more anatomical
and clinical than biological, but base of tongue
cancers are more difficult to detect. Oropharynx
cancers may be treated with comparable disease
control with surgery (usually with postoperative
radiation therapy) or chemoradiation therapy.
The use of brachytherapy with EBRT results in
excellent functional outcomes and good quality
of life preservation [27]. The same appears to be
true for tonsillar cancer. A comparison study of
surgery and brachytherapy with EBRT revealed
equally high local control but more trismus with
surgery and more (transient) soft tissue necrosis
with brachytherapy [2830]. Traditional surgery
may be replaced by transoral robotic surgery
(TORS) for some cases of oropharynx cancer; it
eliminates the need for tracheostomy and reduces
the complexity of surgical access [31]. There are
no randomized prospective trials to compare
IMRT with or without brachytherapy to standard
surgery or TORS for these cancers.
The main role of brachytherapy in oropharynx

is as a boost to EBRT. Base of tongue, tonsil, and
soft palate cancers are all accessible and amenable to brachytherapy. Tracheostomy is often, but
not always, performed to protect the airway during brachytherapy or the oropharynx. Combined
EBRT and brachytherapy for soft palate cancers
has the advantage of leaving the soft palate intact
and usually avoids the need for a prosthetic
device. The use of brachytherapy in pharyngeal
wall cancer minimizes injury and removal of the
pharyngeal constrictors.
3.6
Nasopharynx
Chemoradiation is treatment of choice for locally

advanced or regionally metastatic nasopharynx
cancer [32]. Brachytherapy boost of early (T1 or
T2) disease with little or no bone erosion and no
intracranial extension is performed by outpatient
placement of an intracavitary applicator under
local anesthesia. In more advanced disease, the
use of brachytherapy is less likely to impact the
outcome because the base of the skull or the
intracranial extension precludes disease encompassing anatomic access [33, 34].
3.7
Hypopharynx, Larynx,
and Trachea
Lesions of the hypopharynx and larynx are technically challenging for brachytherapy due to the
relatively inaccessible location, laryngeal cartilage concerns, and vascular anatomy. For the
most part, these cancers are treated with either
surgery or radiation therapy or some combination. Brachytherapy is used in selected cases as
salvage or for palliation. Outpatient intraluminal brachytherapy is applicable to tracheal stomal recurrences and for lesions in the trachea.
Stomal recurrences are usually palliative
whereas early lesions of the trachea can be
treated with brachytherapy or EBRT and brachytherapy with curative intent. Extensive peristomal disease may require the use of complex
interstitial implants.
77
3.7.1
Head and Neck Brachytherapy

Used for Salvage of Previously
Irradiated Patients
Local recurrence of disease and new primaries in
previously irradiated patients are common.
Normal tissue tolerance places limits on additional radiation therapy, so brachytherapy has
been used when the disease is amenable and the
patients general condition allows a procedure to
be performed. The surgical option should always
be considered and the condition of the previously
irradiated tissues assessed before proceeding
with salvage brachytherapy. Doses to the spinal
cord need to be reviewed, so that total spinal cord
can be kept within tissue tolerance. Salvage interstitial implant are often complicated and challenging procedures [3545].
Techniques of Head
and Neck Brachytherapy
4.1
Overview
The techniques for brachytherapy are as varied as

the modality itself. The GEC-ESTRO handbook
is an excellent reference and overview of head
and neck brachytherapy [2].
4.2
Dental Evaluation
and Prosthodontics
Dental evaluation before radiation therapy is

an essential part of treatment planning. The
teeth should be cleaned, caries filled, and
extractions performed as needed. Dental trays
are prepared for long-term fluoride treatment
to prevent tooth decay. Management of gingivitis is essential for prevention of bone necrosis (BN). Custom-fitted mandible trays with or
without shielding for displacing normal tissues
from the radiation sources are valuable and
necessary devices prepared for the reduction of
dose and radiation injury of the mandible and
other normal tissues. The proper use of these
devices reduces the likelihood of mandible
necrosis [4649] (Fig. 1).
D.J. Demanes
78
Fig. 1 Oral tongue implant with mandible spacer (insert)

shown in treatment position
Management of tissue reactions after radiation

affects the extent and severity of long-term complications. Extractions after radiation therapy
should be avoided unless there are strong indications to do them. Only dentists or maxillary facial
surgeons experienced in the care of radiation
therapy patients should do these procedures.
Hyperbaric oxygen therapy before and after the
extractions may be indicated to reduce complications of the procedure and improve wound healing [50]. Hyperbaric oxygen has also been used
to treat soft tissue and bone necrosis after treatment of head and neck cancer [51, 52].
4.3
Tracheostomy and Airway

Management
Brachytherapy involves the placement of hardware that can impair the airway. Interstitial catheters may be associated with edema, bleeding,
and obstructing secretions, which can accumulate around the devices and obstruct the airway.
Urgent intubation with a brachytherapy device in
place can be difficult so the airway must be
assessed before and during the performance of
the brachytherapy procedure. The patient should
be consented for a tracheostomy, and there must
be an anesthesia plan on how to best secure the
airway (direct, fiberoptic, transoral, or transnasal
intubation). The patient should not be paralyzed
until the airway is clearly manageable.
Fig. 2 Base of tongue implant with tracheostomy and

Omni flexible connector to facilitate access for needle
placement
The lesion size and location, prior to surgery or

radiation, the dental status, the presence of trismus, and the general condition of the patient all
affect decisions about airway management and
whether to do a prophylactic tracheostomy. In general, smaller anterior lesions pose less airway risk.
Trismus, thick secretions, a full set of teeth, and
medical infirmity are detrimental. Standard direct
or video-assisted transoral intubation is done for
easier airway control. Oral intubation impedes the
brachytherapy procedure, so if there is no tracheostomy planned, nasal intubation using a rightangle endotracheal (RAE) tube which curves
superiorly over the forehead out of the operative
field is preferable. When in doubt about the airway, a tracheostomy should be performed. In
patients with a prior tracheostomy or a tracheal
stoma, a cuffed Armor tube can be used. Another
very useful device is an Omni tracheostomy
connector device. It has a short flexible tube with a
low profile that allows the airway control device to
be out of the way and fixed on the patients chest
so that it does not interfere with access to the submental region during the implant (Fig. 2).
If intubation is not feasible, then an awake
tracheostomy can be done under local anesthesia
with the patient sedated. On occasion, the implant
turns out to be more extensive than expected, in
which case a tracheostomy can be performed
after completion of the implant. A size 68 cuffed
(fenestrated) tracheostomy tube is most suitable.
The fenestration is helpful for alleviating later

airway obstruction related to the tracheostomy
cuff, which can become encrusted with secretions over the course of several days. The fenestration also facilitates decannulation. Most
patients who need to return to the operating room
for implant removal should probably have a tracheostomy and vice versa. The tracheostomy is
typically removed the day after the implant catheters are taken out, and in most cases, the tracheostomy is removed prior to hospital discharge.
Intracavitary
and Intraluminal
Applications
5.1
Intracavitary Custom
Applications
The head and neck region has complex anatomy

with natural cavities and potential spaces created
by surgery that affect placement of radiation
sources; they include the nasal cavity, nasopharynx, trachea, oral cavity, external auditory canal,
sinuses, and orbits. The nasopharynx presents a
small, somewhat irregular accessible site for intracavitary brachytherapy. The nasal cavity is more
accessible, but more irregular and less amenable to
standard shaped brachytherapy applicators. The
external auditory canal is another cylindrical site
occasionally treated with intracavitary brachytherapy. Various custom applicators can be designed
and constructed by maxillofacial prosthodontics to
fit in and around accessible lesions such as the lip
or hard palate, which serve to position the applicator and displace normal tissues [5356].
5.2
79
to the soft palate. The Rotterdam dual-channel

applicator is a more suitable device; it is slightly
more complicated to insert, but the dosimetry is far
better than the symmetrical balloon [34]. The
patient may require some sedation, and the mucous
membranes should be topically anesthetized before
insertion. Small (1012-French) feeding tubes are
inserted through the nose until they present in the
oropharynx. They are retrieved through the mouth
and threaded into the two channels of the Rotterdam
applicator. The assembly is pulled upside down and
backward through the mouth so that it seats correctly into the nasopharynx with channels presenting out each nostril. This two-channel applicator
has a tissue spacer to displace the soft palate away
from the sources while the dorsal part of the applicator is pressed snugly onto the nasopharyngeal
mucosa. There are two versions; one with parallel
channels and the other with somewhat lateralized
channels to improve dosimetry. The applications
are given on an outpatient basis (Fig. 3).
5.3
Supraglottic Larynx
Custom applicators have been invented based

upon laryngeal mask anesthesia (LMA) devices.
This applicator can be used for a variety of indications. It requires anesthesia to apply. It is a
relatively simple applicator to insert, and it permits custom source positioning [57].
Nasopharynx
Intracavitary brachytherapy can be used as a boost

for EBRT in NPC without major base of skull bone
or intracranial involvement. One technique is to
place symmetrical balloon-type applicators directly
through the nose and into the nasopharynx. Such
applicators, however, are not customized to fit the
nasopharynx, and they give undesirably large dose
Fig. 3 Double feeding tubes are inserted in the nose and

exit the oral cavity for placement of the Rotterdam nasopharynx applicator
D.J. Demanes
80
5.4
Trachea and Tracheal Stoma
Primary or metastatic cancer in the trachea is

amenable to intraluminal brachytherapy. The
patient is sedated and prepared for bronchoscopy.
One or more closed-ended 56-French endobronchial brachytherapy catheters are inserted
into the anesthetized trachea through biopsy port
of the bronchoscope. As the scope is withdrawn,
the brachytherapy catheter is simultaneously
advanced (using a wire) until the bronchoscope is
removed, leaving the brachytherapy catheter in
the desired location. Inability to control the position of endobronchial catheters within the relatively large trachea lumen is a dosimetry
limitation, which can be somewhat mitigated by
the use of multiple catheters. A larger centering
catheter (Fritz adjustable intraluminal catheter)
has been designed to improve the dosimetry, but
its size prevents it from fitting through a bronchoscope and poses some challenges for use in the
intact airway. It can be inserted into a tracheal
stoma. Other solutions for patients with intraluminal tracheal stoma recurrence have been designed.
One such device was fashioned from a tracheal
stent, an endobronchial catheter, and a tissue
spacer to allow custom dosimetry and delivery of
radiation to the involved side of the tracheal stoma
with sparing of the opposite wall [58]. A typical
course of intraluminal HDR brachytherapy is 35
sessions with or without EBRT.
5.5
Postoperative Mold
Brachytherapy (Sinuses, Nasal
Cavity, or Orbit)
Cancers of the sinuses or orbit are most commonly treated with surgery. In some cases, the
pathological margins are close or positive or
there may even be gross residual disease.
Depending upon the circumstances, brachytherapy alone or in combination with EBRT may be
applied to enhance local tumor control. Customshaped applicators or molds with multiple
embedded channels are made in conjunction with
the maxillofacial and prosthetics department.
The catheters located within the custom form-
Fig. 4 Custom prosthodontic device with catheters

embedded for postoperative intracavitary application
Fig. 5 Complex interstitial brachytherapy with tissue

displacement device for T4N0 buccal cancer treated in
combination with external beam
fitting device can then be applied directly to the

target (Fig. 4). Treatment is given as an outpatient series, usually without sedation or anesthesia. These special applicators may also be
designed for a combination of intracavitary and
interstitial brachytherapy (Fig. 5).
5.6
Complex Interstitial
Brachytherapy
Head and neck brachytherapy is mostly performed as an interstitial implant. Virtually, any
soft tissue can be implanted. The complexity and
risk of the procedure are related to the lesion size,

its anatomic location, and the relationship of the
implant to bone and vascular structures. The
implant design, catheter distribution, and dosimetry are always customized to accommodate the
highly variable clinical circumstance. The implant
process can be described as minimally invasive
(i.e., no incision), but it is complex, spatially challenging and often time-consuming to perform.
Edema can occur as the implant proceeds, which
can affect the process of catheter insertion and
subsequently impact the dosimetry and clinical
management. In general, the salivary glands can
be ignored as organs at risk, but bone, especially
the mandible, and blood vessels cannot.
5. Antacid medications to prevent stress peptic

ulceration as needed.
6. Nasogastric feeding tube placement (usually
a wire-guided 12 French) unless the patient
already has a percutaneous endoscopic gastrostomy (PEG).
7. Intensive care unit (ICU) or similar level of
care monitoring is recommended for patients
with fresh tracheostomies, questionably stable
patients, patient with implants anywhere near
the major blood vessels, or those where there
are concerns about secretion production or
mental status.
8. Routine postoperative orders (Appendix B).
5.8
5.7
Clinical Management
of the Head and Neck
Brachytherapy Patient
The clinical management during the brachytherapy procedure should be standardized. There is
no literature consensus about some of the recommendations presented here; they are the policies
of the author. Please see appendices A and B for
template order sets, which are presented as example
ideas
rather
than
patient-specific
recommendations.
Perioperative measures:
1. Routine preoperative orders (Appendix A).
2. Patient comfort: patient-controlled analgesia
(PCA) usually hydromorphone, if patient is
able to manage it.
3. Prophylactic antibiotics: intraoperative antibiotics typically cefoxitin (or levofloxacin and
clindamycin if penicillin allergic). The author
prefers continuation of antibiotics during the
entire time the applicator is in place. This policy has led to low infection rates of approximately 12 %.
4. Dexamethasone 810 mg given just before
the procedure and may be given daily until the
implant is removed. It is not needed for all
cases (such as smaller or more superficial
implants) and must be used with caution in
diabetic patients.
81
Implant Timing and Target

Volume
The implant may be done before or after EBRT

for combined treatment indications. The advantage of performing brachytherapy first is that the
lesion is most apparent for implantation. The
advantage of administering EBRT or chemoradiation first is to shrink the lesion and make it less
friable and easier to implant. It may be debated
whether to implant the original extent of disease
or just the residual gross disease volume. These
concepts have been addressed by GEC-ESTRO
using the terms (1) gross tumor volume (GTV)
for scan or clinically apparent residual disease at
the time of brachytherapy, (2) high-risk clinical
tumor volume (HR-CTV) for some margin
around the GTV, (3) intermediate risk (IR-CTV)
for the original extent of gross disease, and (4)
low risk (LR-CTV) for regions that may have
harbored undetectable microscopic disease.
The challenge with making a rule is that tumor
regression is variable and there are no compelling
studies for guidance of implant volume in the
head and neck. The author prefers to implant a
volume closer to the original extent of disease or
at least give a generous margin to residual palpable disease. One can always elect not to use certain catheters or to treat a smaller volume than
implanted or to shrink the dosimetry volume during the course of brachytherapy. If in doubt, it is
better to place more rather than fewer catheters.
D.J. Demanes
82
In addition, if the physician is knowledgeable

and sufficiently experienced, gross adenopathy
can be implanted with these same concepts in
mind. A clear strategy for distributing and integrating the internal and external radiation therapy
components is best developed before starting
radiation therapy.
5.9
The Implant Procedure:

Needle Insertion
Needle insertion is the first of a two-step process, and brachytherapy catheter insertion is the
second step. The level of difficulty of inserting
open ended interstitial needles (usually 17
gauge) depends upon the tissue location and its
degree of fibrosis associated with disease or
prior surgery or radiation therapy. At 15 cm
long, they are relatively easy to use and usually
sufficient for the head and neck region. It is best
to use 30 bevel metal needles because they
pass through tissue with reasonable facility.
They are sharp enough to penetrate the skin and
cervical fascia, yet their tips can be safely palpated and advanced through tissue (never do
both simultaneously). Once inserted beneath
the skin, the needles can be carefully advanced
(not stabbed) through the tissue so they can be
moved past rather than through the vessels.
Sharper needles (14 bevel open ended) are
rarely necessary and not recommended, except
in cases of extreme fibrosis, because they are
more likely to enter vessels, and it is more dangerous for the physician to palpate the sharper
needle tips during insertion (Fig. 6).
5.10
Direct Catheter Insertion

(Exchanging the Needle
for the Brachytherapy
Catheter)
The second step of the process is to replace the

needle with an implant catheter (Fig. 7). It is
safest to insert needles and replace them with
catheters one needle at a time. Brachytherapy
catheters come with an internal stent, which
Fig. 6 Bimanual technique of needle insertion during

tube and button interstitial tongue brachytherapy
procedure
a. Leader pulled until catheter
button is seated
b. Insertion of next trocar
Fig. 7 Catheter insertion method for interstitial tubes and

buttons with silk ties during a tongue implant (Reprinted
from Demanes et al. [59])
helps prevent the catheters from stretching and

thinning as they are pulled through the tissue. It
must be removed with wire strippers to make
the catheter hollow and ready for source insertion. For direct catheter insertion, the beveled
open end of the trocar presents visibly at the
mucosal surface. A brachytherapy catheter, with
a narrow hollow proximal leader and a larger
diameter distal closed-ended functional portion,
is prepared by adding a small button on the end
to fix the catheter at the mucosal surface. Prior
to catheter insertion, a 30 in. #1 needless silk
suture is tied, with ends of equal length, to one

of the two side holes of the button. The leader
end of the assembly is threaded with medium
smooth pickups into the (face-up) needle bevel
until it presents at the proximal end of the needle, which exits the skin. The needle is then
removed and the leader is pulled to seat the hollow catheter and button snugly, but not too
tightly, on the (distal) mucosal surface.
A colored-coded external fixing button is
threaded over the leader and pushed to the skin
surface to make both ends of the catheter stable.
Internal buttons are usually flat and preferably
countersunk, so the tip of the catheter does not
project above the level of the button. The end of
the silk ties, attached to the mucosal buttons, is
left outside of the mouth to aid later in retrieval
of the tube and button during the removal procedure. The silk ties are gathered, twisted into a
bundle, tied together, and covered with a inch
Penrose drain. The ties are fixed externally to
one of the entry site fixing the buttons, so they
cannot be swallowed (Figs. 8, 9, and 10). Notice
the metal buttons in Fig. 10, which are used to
hold LDR source ribbons in place. They can
also be used to close one end of a double leader
catheter when they are used for loops or arches
by leaving some portion of the inner leader
within the catheter.
83
Fig. 9 Axial CT of tongue implant dosimetry with color

wash isodose display
Fig. 10 Base of tongue implant with silk ties gathered

and covered with -inch Penrose drain, which will be
fixed to one of the external fixing buttons to prevent the
patient from swallowing it
5.11
Fig. 8 Interstitial tube and button with silk ties (used

later for catheter removal) during implantation of a T4N0
oral tongue cancer
Wire-in-Leader Catheter
Insertion
When the bevel end of the trocar is not visible, the

brachytherapy catheter can still be inserted by a
method called the leader-in-wire technique [59].
A 27-gauge wire is inserted into the skin entry
(proximal) end of the trocar and advanced until it is
palpable at the internal beveled end. The wire is
carefully directed with the palpating double-gloved
finger superiorly without kinking it by applying
continuous gentle pressure on the external end of
the wire rather than pulling it from the inside. Once
the wire is visible in the oral cavity, it is retrieved
D.J. Demanes
84
from the mouth. A small clamp is placed on the

external (proximal) end to prevent the external part
of the wire from slipping into the needle. The thin
hollow leader of the catheter (with the tip squared
off with scissors) is threaded over the part of the
wire presenting from the mouth for 46 in. (at minimum the thickness of the tissue being implanted).
The wire and leader are fixed together by placing a
tonsil clamp on the leader outside the mouth near
the end of the wire. The end of the wire, projecting
from the skin side of the needle, is then grasped and
pulled to seat the leader into the bevel of the needle, so it wont fray as it is being pulled through the
tissue. As the external catheter and wire are pulled
out through the skin, the tonsil clamp advances into
the mouth until the needle finally exits the skin and
the leader becomes visible. The leader is grasped,
the tonsil clamp is released, and then the wire is
pulled out and discarded. The needle is set aside for
reuse. The catheter is then pulled into position with
the button on the mucosal surface as usual (Fig. 11).
5.12
Avoidance of Vascular Injury
Vascular structures are to be avoided during

interstitial implants. Thin-walled veins are more
likely to be penetrated than thicker-walled arterb. wire is guided intraorally by
double gloved fingertip until
accessible for retrieval
ies, where consequences are more serious. The

technique to avoid implanting vascular structures
is somewhat difficult to describe because there is
some feel to it. The common and internal
carotid arteries are of particular interest in head
and neck brachytherapy because of the potential
for bleeding and neurovascular injury about
which the patient should be apprised in advance
of the procedure. The course and anatomy of the
large blood vessels must be known, and the relationships to the target volume must be understood
by the physician doing the implant. Smaller arteries are usually not at great risk of injury because
they are more difficult to penetrate with brachytherapy needles and the consequences are clinically less significant. Placement of a
brachytherapy catheter into the carotid artery or
jugular vein, although undesirable, is not necessarily associated with a morbid clinical outcome.
With proper technique, the risk of major bleeding
or stroke in the unoperated neck is low. Risks are
increased, sometimes significantly, in patients
with prior radical neck dissection, ulcerated or
necrotic lesions, and preexisting vascular disease. Major bleeding during the brachytherapy
insertion is unusual because the brachytherapy
catheters tamponade penetrated vessels. The
greatest risk for bleeding is during implant
removal when the catheter is taken out of an inadvertently penetrated vessel (Fig. 12).
Wire, distal end

c. Wire retrieval (fingers,
clamp or endoscopic)
to extraoral position
a. Straight 26-gauge wire is inserted

into the external end of the trocar
Wire, proximal end
Fig. 11 Wire-in-leader technique for loading catheters,

which are not directly visible for catheter loading (see text
description) (Reprinted from Demanes et al. [59])
Fig. 12 Complex interstitial implantation of T3N2 oropharynx cancer (base tongue, tonsil, and soft palate)
including implantation of adenopathy
5.13
Bone Issues
The mandible, maxilla, hard palate, pterygoid

plates, base of skull, and hyoid bone may be
obstacles to the placement of brachytherapy catheters. When significantly involved, they are
challenges to good dosimetry. Surgery and external beam radiotherapy should be considered for
any resectable lesion with significant bony
involvement. The body of the mandible is at
greatest risk for necrosis, so attempts should
always be made to displace the brachytherapy
catheters from resting directly upon the gingiva.
Spacers, with or without shielding, should be
used when feasible. Disease with limited bone
involvement can be managed by wrapping catheters around the bone. A strongly curved catheter,
however, can kink and prevent passage of the
radiation source (especially with HDR afterloading), so catheters with a tightly curved radius
must be checked to be sure they are not obstructed.
5.14
Double Leader Arches
When lesions involve midline structures, such as

the soft palate, posterior pharyngeal wall, or nasopharynx, double leader catheters without buttons
are preferred. They permit creation of an arch,
which crosses from one side of the site to another.
A pair of beveled implant needles is inserted symmetrically on either side of the neck or face. Then
each needle is advanced into tissue, so it exits the
mucosa at or near the midline. Each end of a double leader catheter is inserted through the mouth
into the matching pair of needles, and they are
advanced until the leader projects from the proximal (skin) end of the needles. The needles are then
withdrawn leaving the leaders protruding from the
skin on opposite sides. The leaders are pulled until
the functional portion of the arch exits the skin on
each side. The catheter lumen can be stopped from
one side (at any point along the arch) by leaving a
segment of the inner leader inside the arch and fixing it at one end with a metal crimping button
(again as seen in Fig. 10). The treatment plan and
virtual image of a palatal arch are shown in Fig. 13
[38, 43, 60, 61].
5.15
85
Dual Catheters and Internally

Connected Buttons to Avoid
Catheter Kinking
Catheters that wrap around bone in an acute angle

have the potential to kink to make the double
leader arch dysfunctional. A better solution is the
use of two independent single leader catheters,
which meet internally. Needles are inserted on
either side of the bone to meet at a common internal mucosal site. Catheters are prepared by connecting their button tip ends together with silk
ties. The two catheters are then inserted like a
double leader catheter to wrap around bone such
as the mandible [62].
5.16
Jackson-Pratt Drain
Scaffolding, Catheter Spacing
and Stabilization
The placement of tubes and buttons is typically

done freehand. The spacing relationships and stability of the catheters, therefore, is subject to variability. A method has been developed using
commercially available Jackson-Pratt drains to stabilize brachytherapy catheters [63]. It has holes at
0.5 cm intervals that can be used to space the catheter entry and exit points and connect them together
as a unit. For the head and neck regions, 10-French
round drains are typically used on the skin (Fig. 14).
The drains are threaded over the needles or the
catheter leaders typically at 11.5 cm intervals to
create stable catheter groupings. Planes of catheters
can be connected with crossing connections to create stable scaffolding. Stabilization and internal
mucosal spacing can be improved by tying selected
buttons together with silk.
5.17
French Hairpin (Guide Gutter)

Technique
A technique was developed and used primarily in

Europe and Asia to facilitate the placement of
sources in the tongue [2, 24, 64]. It consists of the
transoral placement of a doubly pointed needle
connected on the ends by a bar, which stabilizes
D.J. Demanes
86
Fig. 13 3D virtual image of the implant catheters and axial color wash isodose of a T3N0 soft palate primary with
extension to tonsil and base of tongue in a previously irradiated patient
5.18
Fig. 14 Base of tongue implant demonstrating the use of

size 10 round Jackson-Pratt drains to space and stabilize
implant catheters
the needles and defines the interval between the

two arms. A series of these devices can be placed
at approximately 1 cm intervals to make a twoplane implant. The procedure may be done under
general or local anesthesia. The guide gutters are
afterloaded with iridium-192 wires for LDR
brachytherapy. This method, to the authors
knowledge, has not been adapted for HDR
brachytherapy.
Entry Site Design

and Catheter and Spacing
Each implant design is unique. Selection of entry

sites can be challenging because of the variability
of the target anatomy, the bony obstructions, and
the need to avoid vascular structures. Catheter
spacing must consider both external and internal
anatomy. In some cases, the catheters converge
(lower base of tongue and vallecula), and in others,
it may fan out (larger oral tongue lesions). Access
to the deep tongue base is limited by the hyoid
bone, and access to the oral tongue is limited by
the mandible. The tentative catheter entry sites and
spacing should be marked on the skin with a sterile
marker before proceeding with the implant.
Integration of implantation of the primary mucosal
lesions with implantation of gross cervical adenopathy, if any, must be planned in advance. It has
been noted that spacing the catheters more widely
at the skin entry and having them converge to the
desired location within the target help reduce the
dose to the mandible, and it is thus believed to
lower complication rates [18]. This is good advice
for LDR brachytherapy with uniform loading.
HDR dwell time optimization can be used to simi-
lar ends, particularly if the catheter entry sites are

somewhat too close together.
5.19
Fully Encompassing
the Lesion
Optimal dosimetry is achieved when the target

volume is fully encompassed by relatively uniformly spaced peripheral catheters. Failure to do
so results in markedly higher than desired doses
(inhomogeneity and possible tissue necrosis) to
the tissues within the implant volume in the
attempt to deliver the full dose to the periphery of
the tumor (i.e., poor dose uniformity). Similarly,
poorly spaced peripheral catheters can lead to
scalloping of the dose margin, which may result
in inadequate target coverage. Uniform spacing
is more important for smaller than larger implants.
Catheter spacing for larger implants can be
increased from 1 to 1.5 cm because of the beneficial effect of the additional source positions on
dosimetry. Correct catheter spacing impacts
complication rates [65].
5.20
Implant Quality
One of the problems with head and neck brachytherapy is that the spacing of catheters and planes
is not known with certainty until the patient has
a post-implant CT scan. When inserting catheters, there is a tendency (especially in the oral
tongue) to have the planes converge at depth
even though they appear to be properly spaced at
the entrance and exit sites. It is therefore important to place the medial plane needles sufficiently
deep (medial) in the tissue to achieve proper
spacing between the catheter planes along their
entire length. Therefore, placement of additional
catheters medial to the target is preferable to
having an implant of insufficient thickness or
volume. Too many catheters too close together
can be easily managed with HDR brachytherapy
where the moving source can compensate by
adjusting dwell times. Additional needle insertions are less harmful to the patient than inadequate dosimetry (poor target coverage or
excessive hot spots).
5.21
87
Tissue Displacement
and Mandible Shielding
The physics (inverse square law) and methods of

brachytherapy provide intrinsically localized
radiation. Advantage may be taken of these principles by tissue displacement devices and shielding. These devices may be as simple as several
tongue blades wrapped together and inserted
between the tongue implant and the mandible or
(preferably) a custom prosthodontic device that
fits snugly on the teeth and gingiva to displace the
implant from normal tissue. Embedded lead
shields further improve the protection. They are
most applicable to lip and oral cavity, but they
may be applied to any site.
5.22
Implant Removal
Implant removal may be simple or complex

depending upon the location and extent of the
implant. Catheter removal is relatively painless,
but the physician must be prepared to manage
secretions, hemorrhage, and the patients wellbeing. Oral cavity, lip, buccal, and neck catheters
can generally be removed in the clinic or at the
bedside. Deeper pharyngeal lesions are best
removed in the operating room under anesthesia
to control bleeding, evaluate the airway, do
wound debridement, and optimize patient comfort. A cuffed tracheostomy tube allows anesthesia to be introduced without a second intubation,
and the fenestration makes it easier for the patient
with a cuffed tube to breathe and to be decannulated. The patient should be paralyzed for removal
to allow optimal internal access. The procedure
should start with a standard head drape without a
sterile preparation and then pharynx should be
thoroughly suctioned and rinsed to eliminate
debris and secretions. The physician will do the
sterile preparation of the brachytherapy catheter
sites during removal.
The most accessible (anterior) and least likely
to bleed catheters are removed first. The Penrose
drain is removed, and the silk ties are separated to
clarify their connections to the catheter buttons.
Tugging on individual ties helps identify the connection. Once the individual assembly has been
D.J. Demanes
88
identified, the external portion of the catheter is

gently retracted from the skin and generously
cleaned with sterilization solution (usually
povidone-iodine unless the patient is allergic).
The surface is depressed to expose the portion of
the catheter beneath the button just deep to the
skin, so it can be cut to minimize introduction of
contaminated material. The remaining portion of
the catheter and the internal button attached to
the silk tie are then pulled from the tissue using
the index finger on the silk tie. The assembly is
delivered through the mouth and discarded.
Catheters are removed sequentially to manage
bleeding one catheter at a time. Deep catheters or
those thought to be located near larger blood vessels are best removed last. The palpating finger
can often locate the mucosal site of the button
that marks where internal pressure should be
applied. Tamponade performed using a single
fingertip to occlude the catheter exit site is preferable to general packing. A catheter count should
be performed after implant removal to assure all
the catheters have been removed. At the end of
the procedure, the oral cavity, pharynx, nasal cavity, and trachea should be suctioned clear and
debrided of secretions and necrotic material. A
terminal direct laryngoscopy should be performed to confirm hemostasis and assess the tissue condition and the airway for the potential for
uncomplicated decannulation. Antibiotic ointment should be applied to external catheter exit
sites and the tracheostomy site, and a clean tracheostomy collar applied. If there is a nasogastric
feeding tube, it can be removed in the operating
room or later when swallowing status has been
determined. As soon as the patients vital signs
and blood pressure are stable, the head of the bed
can be raised to facilitate secretion management,
to decrease head and neck venous pressure, and
to unweight the diaphragm for improved breathing and recovery.
5.23
Site-Specic Commentary
Lip The lip is an accessible site amenable to

brachytherapy. Tube and button techniques and
steel needles in a template have been used. Plastic
tube catheters are generally easier for the patient

to manage.
Oral Commissure This area is problematic in
that the tissues are thin and mucositis is exacerbated by motion during eating, speaking, and
facial expression. The superficial aspect of the
tumor must not be underdosed, so it may be necessary to place catheters outside the lesion on the
surface. Superficial lesions are potentially amenable to a wrap technique where the catheters are
positioned transversely in a U-shape across the
lip on the mucosa, vermillion region, and skin
around the lip to sandwich the lesion without an
interstitial component. Implant displacement
away from the gingiva and bone by custom-fitted
dental prosthetic devices reduces the dose and
injury to normal structures [2, 54, 6669].
Buccal Mucosa The buccal mucosa extends
from the anterior commissure to the intermaxillary fissure and from the mandible to the maxilla
with attachment at the gingival buccal sulci.
Implants are similar to lip except posteriorly
where the structures end medially near the retromolar trigone and the intermaxillary fissure.
Posterior lesions must be implanted in such a
way to fully encompass the posterior extent of
the lesion with either a looping catheter or a perpendicularly crossed end near the posterior border of the masseter muscle. Displacement of the
soft tissue with a dental device is indicated, keeping in mind that lesions in the sulcus or which are
otherwise adjacent to bone must be encompassed.
Although it is difficult to distinguish during the
procedure, implantation of the parotid (Stensens)
duct is, in principle, to be avoided [2, 7073]
(Fig. 5).
Oral Tongue Cancer of the oral tongue occurs
most commonly on the lateral undersurface. The
approach for brachytherapy catheters placement
is to utilize the relatively narrow region between
the body of the mandible and the hyoid bone.
From there, the tongue fans out from the tip to the
base and in the normal state rests with a deformable mushroomlike dorsal surface projecting
from the floor of mouth. Implantation must take
into consideration the anatomic access and the

extent and location of the lesion. There are three
implant methods: (1) plastic tube loop, (2) guide
gutterhairpin, and (3) the single leader plastic
tube and button. The latter is most suitable for
HDR because the single leader method avoids the
tight curves that are troublesome for the HDR
afterloader. The plastic tube loop and hairpin
techniques are well described in brachytherapy
literature [2, 18, 24, 56, 64, 74] (Figs. 6, 7, and 8).
The single leader catheter with button technique should begin with the lateral plane and start
with the most anterior position, especially if the
lesion is near the tip. The needle is inserted into
the submental skin and passed through soft tissue
into the tongue musculature. A finger in the floor
of mouth is used to guide the needle along the
undersurface of the tongue to exit at the junction
with the dorsum (where the mucosa changes
from smooth to rough by taste buds). Care must
be taken not to accidentally impale the guiding
finger, so advancement of the needle and palpation are not done simultaneously. The needle is
replaced with the single leader catheter with button and silk tie by inserting the leader of the catheter into the beveled tip and advancing it until it
exits the other end of the needle. The needle is
then removed leaving the leader exposed. The
catheter can then be pulled to bring the functional
hollow catheter into the tissue with the button
coming to rest on the dorsal mucosal surface.
Subsequent needles are inserted in a parallel
fashion between 1 and 1.5 cm apart. The cutaneous entry sites generally follow the body of the
mandible somewhat diagonally, from anterior
medial to posterior lateral, approximately 0.5 cm
medial to the bone. Lateral entry, if is located too
close to the mandible, will impede needle placement and potentially cause overdose to the bone.
If entry is too medial, there will not be enough
space for the medial planes. In the authors opinion, a second more medial plane is usually
required to generate a volume implant for proper
dose uniformity and complete target coverage.
The second plane should be at least 11.5 cm
deep and parallel to (i.e., medial) the first plane.
Button to button touching on the tongue surface
89
is a good guide to catheter spacing. It is advisable

for the needles of the second plane to enter the
skin and be directed more medial than might be
expected before heading superiorly to the exit in
the dorsum in order to avoid catheter convergence deep in the tongue upon tongue relaxation
when the retraction is eased. A third plane may be
needed if the lesion is bulky or if there is any
doubt about catheter spacing. The additional
catheters will be valuable for dosimetry in cases
where unintended catheter convergence has
occurred. Generally, fewer catheters are required
for more medial than for lateral planes [61, 75,
76].
Floor of Mouth Floor of mouth implants must
be directed into a relatively limited horseshoeshaped space between the gingiva and tongue.
These lesions are challenging because of the
thinness of the mucosa and their relationship to
the mandible. In the relatively narrow confines of
the floor of mouth, the catheters may need to converge somewhat from the skin to the mucosal surface to improve dose uniformity [18]. It is more
relevant to LDR brachytherapy than HDR where
dwell time modulation can help achieve the
desired uniformity. Tumor extension to the
tongue is easily implanted with a plane of catheters similar to the lateral plane of a tongue
implant, but gingival extension is more problematic. When possible, lesions involving the gingiva
should be managed surgically. When surgery is
not an option, brachytherapy catheters should be
placed approximately 0.5 cm from the gingival
surface of the lesion. It is necessary to understand
the sloping anatomy of the mandible in order to
maintain a suitable (>0.5 cm) distance from the
mandible during the implant. Submental needle
entry into the skin must not be too close to the
edge of the mandible because it will cause the
needle to exit the mucosa too close to the attachment of the tongue. There are two possible solutions to how to bring the treatment sufficiently
superior to the floor of mouth to encompass the
gingival extension. One solution, used for LDR,
is to wrap the brachytherapy catheter over the
mandible with submental and lower lip entry
sites [77]. Teeth impede but do not necessarily
90
preclude such an approach. The other solution,

more suitable to patients with teeth and when
using HDR, is to place multiple buttons on the
ends of the catheters in the floor of mouth, so the
source projects above the mucosa far enough to
provide dose to the medial gingiva [62].
Base of Tongue These implants pose a greater
airway risk, and tracheostomy is advisable. The
base of tongue converges from a broad upper portion to a relatively more narrow termination in the
vallecula. The implant design, therefore, must
account for the radial anatomy spacing of catheters by inserting them approximately 1.52 cm
apart on the skin and allowing them to converge to
1 cm spacing where they enter the mucosa. Five
converging catheters are sufficient for the most
inferior or deepest row even for a bilateral vallecular lesion with extension to the lateral pharyngeal wall. As the implant proceeds superiorly, a
somewhat more parallel needle path can be used.
It is generally advisable to insert the deepest and
medial catheters first because reaching this location with the palpating finger becomes increasingly difficult and the lesion progressively harder
to appreciate as catheters and buttons are added.
Gentle on-and-off countertraction can be applied
to the initial catheters to help guide subsequent
needle trajectories. The hyoid bone, anchors and
protects the base of the tongue. Therefore, for
deep lesions, the needle path may need to pass
inferior to the hyoid bone, or the needles may be
superior to it for lesions that spare the vallecula.
The paired lingual arteries are unlikely to be
pierced, but they are occasionally a source of
bleeding during these procedures. The wire-inleader technique is often used for base of tongue
implants because the internal needle tips are often
not visibly for direct loading [7880].
Figure 10 shows an LDR base of tongue
implant, and Fig. 11 is one drawing of the wirein-leader technique.
Tonsil Like the base of the tongue, the tonsil is
amenable to brachytherapy, except that the ramus
of the mandible impedes access. This barrier can
be circumvented by the use of looping catheters or
D.J. Demanes
a dual catheter technique as described previously.

The anterior loop is limited superiorly by the
zygoma and maxilla and inferiorly by the body of
the mandible. The posterior loop is more broad
and open to the lateral pharynx. Spread of the
lesion to the base of tongue or pharyngeal wall
can be implanted with the single leader catheters
with buttons and silk ties. The risk of vascular
injury and bleeding is somewhat greater for tonsil
implants, which are lateral and more posterior in
the neck and, therefore, closer to the carotid artery
and jugular vein [28, 29, 33] (Fig. 12).
Hard and Soft Palate The soft palate is
implanted with a double leader arch technique
[38, 43, 51, 60] (Fig. 13). Three, or sometimes
four, catheters are used. The first catheter entry
site is 1 cm below and slightly posterior to the
angle of the mandible. The examining finger
must be inserted into the oral cavity and placed
behind the soft palate to appreciate the correct
trajectory through the lateral pharyngeal fold
(posterior tonsillar pillar) then up and along the
free border of the soft palate so that it exits the
mucosa near the midline. A contralateral catheter
is similarly inserted so that the beveled tips meet
at or near the midline. A double leader catheter is
inserted, as previously described, to create an
arch. The second catheter is inserted 1 cm superior and slightly forward of the first catheter just
behind the angle of the mandible. It runs through
the anterior tonsillar pillar into the soft palate
about 1 cm anterior to the first catheter. If there is
room, a third catheter can be inserted behind the
mandible. The most anterior catheter is inserted
in front of the angle of the mandible at the junction of the ramus and the body. It passes posterior
to the maxillary tubercle and through the tissue at
the junction of the soft and hard palate. If disease
extends to the hard palate, then more anterior
catheters can be inserted that pass over the gums
or between the teeth. They are sutured to the surface of the hard palate and spaced and stabilized
by the Jackson-Pratt drain technique.
Alternatively, a prosthodontic surface applicator
device can be created as previously described and
referenced [53]. Cancer of the hard palate is more
often treated with surgery than radiation therapy.
Nasopharynx and Posterior Pharynx Early

nasopharyngeal cancers may be managed with an
intracavitary brachytherapy boost; however, more
extensive disease (primary or recurrent) may
require a complex interstitial implant. Deep invasion into the skull base or through the foramina is
beyond the dosimetric range of curative transcutaneous brachytherapy. The complex interstitial
implants are technically challenging and may be
done independently or in conjunction with intracavitary applications. Two approaches have been
described. One is through the lateral face and neck,
and the other is endoscopic guided through the
nose. Both approaches are facilitated by CT or
fluoroscopic image guidance. CT is preferable, but
it is not widely available in most operating rooms
where the lateral procedure should be performed.
In the lateral approach, implant needles
(15 cm) are inserted on either side of the face to
meet in the midline in an arch technique, or alternatively, a single long needle (20 cm) can be
passed entirely across the pharynx to exit the contralateral face like the pencil in Grants Atlas of
Anatomy. The entry site for the first catheter is
below the zygoma through the mandibular notch.
It traverses the superior nasopharynx above the
torus tubarius. The leader-in-wire and arch techniques can be used if paired needles enter the
nasopharynx as extracting the wire from the nasopharynx is technically challenging. On the other
hand, traversing the entire skull from mandibular
notch to mandibular notch with one long needle
may require image guidance, but it is easier to
load the plastic catheter. A second needle is
inserted just behind the head of the mandible posterior and slightly inferior to the first needle.
Forward thrust of the jaw facilitates needle insertion and exit. This second catheter traverses at the
level of the junction of the roof and posterior wall
of the nasopharynx. One to three additional catheters can be placed at 11.5 cm intervals in the
posterior pharyngeal wall going fully across from
side to side anterior to the carotid arteries. As one
proceeds inferiorly, the tissue volume expands,
and there may be need to place an additional row
of single leader catheters with buttons which terminate in the lateral pharyngeal wall just anterior
91
to the traversing plane. More inferiorly, the large

vessels may be within the needle trajectory (possibly tortuous or displaced by disease or prior
treatment). Preoperative CT or MRI of vascular
anatomy is advisable before proceeding with
these kinds of implants [81] (Figs. 15, 16, and 17).
The endoscopic approach consists of direct
visualization of the lesion with a rigid scope and
the guided placement of specially formatted
curved catheters. The extent of the lesion and its
relationship to the carotid artery and jugular vein
is determined by CT or MRI image guidance
before or during the procedure. The lateral extent
of the implant by this method is limited by the
anatomic constraints of access through the nose
and the nature of the catheters, but it is probably
easier to perform and might be more widely
applicable than the lateral method [82, 83]. Nasal
packs with hollow tubular centers may also be
used.
Fig. 15 Complex interstitial and intracavitary implant of

a recurrent nasopharynx cancer (previously irradiated)
with HDR transfer tubes connected to brachytherapy
catheters
92
Nasal Vestibule The nasal cavity has a complex

internal structure. It was already addressed as a
potential site for intracavitary brachytherapy
mostly in the postoperative setting. Lesions of the
nasal vestibule (columella, nasal alae, and distal
nasal cavity) may be treated with interstitial techniques. The implant may consist of tubes and buttons, or it can be done with closed-ended catheters
D.J. Demanes
with obturators implanted through a template or

stabilized with Jackson-Pratt drains or done freehand. Transverse or axial trajectories have been
used. The principles of catheter spacing are the
same as for other mucosal sites just described.
The presence of cartilage and bone affects the
execution of interstitial brachytherapy of this
region [8486].
Fig. 16 Anterior-posterior and lateral plane film views of an extensive recurrent posterior pharyngeal wall cancer in a
previously irradiated patient
Fig. 17 Interstitial implant of the ethmoid sinus, medial

orbit, and bridge of the nose in a patient who had
recurrent sinus cancer, after maxillectomy, orbital
exenteration, and postoperative external beam radiation
therapy
Paranasal Sinuses The challenges for paranasal

sinus brachytherapy are that access is limited by
bony anatomy and the clinical presentation is
often of advanced disease with bone involvement. Surgery is the treatment of choice in most
cases. Surgical margins may be close or positive,
and preservation of normal structures, such as the
eye, can be difficult. The use of brachytherapy
may enhance the therapeutic index by extending
the surgical margin and reducing radiation morbidity associated with external beam.
Brachytherapy may be intraoperative or postoperative. After the lesion is resected, brachytherapy catheters or devices can be fashioned. It is
also possible to drill or remove bone and fashion
a stable applicator from plastic catheters and
other materials. If a shielded operating room is
available, treatment can be delivered in a single
intraoperative fraction. Alternatively, afterloading catheters can be inserted at the time of the
procedure, and treatment can be delivered
through the usual process of simulation, computerized dosimetry, and source loading (LDR,
PDR, or HDR) [87, 88] (Fig. 18).
Peristomal Recurrences Recurrent cancer
involving the tracheostomy stoma can result in
necrosis, pain, bleeding, and airway stenosis or
obstruction. These lesions, often present in
previously irradiated field, are potentially clinically morbid and usually difficult to resect.
Brachytherapy catheters can be inserted directly
into these lesions with the tube and button technique with proper attention to maintenance of
airway patency [89] (Fig. 18).
5.24
Brachytherapy of Cervical
Adenopathy
Lower Neck Adenopathy in the lower neck can

be implanted with a tangential (to the vertical
axis of the spine) skin-to-skin catheter placement. In the lower neck, the great vessels are
anteriorly situated, and they may traverse the
intended implant target volume. In the nonoperated neck, it is possible to place catheters both
deep (between the vessels and the vertebrae) and
93
Fig. 18 Interstitial brachytherapy of a deeply invasive

peristomal recurrence of larynx cancer
superficial to the carotid to fully encompass adenopathy involving the carotid space. Ultrasound
and CT image guidance are helpful, but equally
important is the technique of gently advancing
the 30 bevel needle through the tissue (rather
than stabbing), so they do not penetrate the artery.
Typically more than one plane is required to create a volume around adenopathy. In patients who
have undergone a prior neck dissection, and especially in previously irradiated cases, the vessels
will have lost supporting soft tissue, and they are
not as pliable or mobile. These unprotected, partially fixed vessels are more prone to penetrating
injury. In these cases, proceed with neck implantation with caution and preferably with image
guidance. Another even more challenging situation is when the lesions ulcerate through the skin
or are associated with a fistula. These circumstances are relative contraindications to neck
brachytherapy [3944, 79] (Figs. 19 and 20).
Upper Neck Upper cervical adenopathy is not
generally amenable to implantation by a tangential approach. The lower border of the mandible
generally demarcates where the tangential technique is no longer applicable. The upper neck is
best implanted with a trans-pharyngeal
approach. A prophylactic temporary tracheostomy is advisable. The carotid artery curves posterior in the upper neck. At the base of the skull, it
is posterior to the vertebral body and behind the
plane of implantation. Image guidance may be
D.J. Demanes
94
helpful, but the mandible usually interferes with

ultrasound. Needles are inserted perpendicular to
the skin and directed into the neck toward the
pharynx. Single leader tube and button catheters
with silk ties are either loaded directly or with the
wire-in-leader technique. Two or more planes
may be needed. These upper neck implants should
be removed in the operating room [90] (Fig. 10).
5.25
Intraoperative Brachytherapy
Brachytherapy can be done with head and neck

surgery, as just described, where disease is
excised, radiation targets are identified, and
brachytherapy catheters are inserted safely
around important normal structures. The catheter
spacing and stabilization technique described
earlier is often helpful [63]. A 10-French flat
drain is placed in the wound perpendicular to the
plane of the catheters to maintain internal catheter spacing. This drain should not be pulled or
adjusted prior to implant removal since it is
attached to brachytherapy catheters. Wound closure must be planned and tested during the catheter insertion to be sure the catheters dont
become distorted in the process. It is advisable to
allow several days for wound healing before
starting radiation treatment. Timing depends
upon the extent of surgery, blood supply, nature
of the lesion, prior radiation, and the relationship
of dose to the tissues that need time to heal. This
approach, which involves afterloading of the
radiation source, takes full advantage of 3D simulation, computerized dosimetry, and normal tissue sparing fractionation of the dose.
Brachytherapy doses can be delivered in the
operating room as intraoperative radiation therapy (IORT). It has the advantage of displacement
of normal structures and wound closure margins
from the radiation dose but lacks the imagedbased precision dosimetry, time for wound healing, and benefits of dose fractionation associated
with postoperatively source loading. It requires
either an HDR-shielded operating room or a
lower-energy source such as generated with lowenergy electronic devices [9193]. Electronic
radiation sources are currently larger and more
cumbersome than radionuclides. Applicators for
Fig. 19 Complex interstitial transcutaneous brachytherapy of low cervical adenopathy in a patient with recurrent
hypopharynx cancer
Fig. 20 Intraoperative placement of brachytherapy catheters and the use of Jackson-Pratt-type drains to position
and stabilize the catheters within the wound. (Larger 10
flat are preferred in wounds in most operative cases
because they are less likely to break off in the wound during implant removal)
these devices, suitable for IORT in the head and

neck, are yet to be fully developed (Fig. 21).
5.26
Permanent Seed
Brachytherapy
Permanent seeds may be used in the head and

neck region when the lesion volume accommodates the sources or there is a surface onto which
a seed-embedded mesh can be applied. Individual
permanent seeds or seeds in needles with absorbable spacers may be injected into gross tumor.
Insertion of seeds into primary mucosal cancer

can be technically challenging because good
source distributions are difficult to achieve in
deformable soft tissue and at mucosal surfaces.
Tissue necrosis at mucosal surfaces may result in
seed loss, degradation of dosimetry, and possible
seed aspiration. Permanent seed implants are
most commonly used to treat recurrent disease
presenting in a definable soft tissue volume.
Permanent seed sources can be individually
injected, inserted as strands on absorbable suture
or embedded in a mesh and sutured onto an
exposed wound surface. Since irradiation begins
immediately upon application, the relationship of
the sources to the tissues may affect wound healing. Three technical challenges with permanent
seeds are as follows: (1) source distributions are
unknown until after the procedure has been completed; (2) once inserted, the sources cannot be
modified; and (3) there is no HDR-like dwell
time dose optimization. Medical personnel are
exposed to radiation and the patient must follow
radiation safety precautions. The advantage of
permanent seeds is their simplicity and efficiency
of source delivery [5, 37, 39, 56, 94100].
Fig. 21 Complex interstitial implant of recurrent larynx

cancer (which, parenthetically, requires direct laryngoscopy for catheter insertion)
5.27
95
Salvage Brachytherapy
Brachytherapy may be used for recurrent cancer at

almost any site in the head and neck region. It can
be applied to recurrent disease at the primary site,
lymph nodes, or other soft tissue locations. Surgery
should always be considered an option, especially
in previously irradiated patients (Fig. 22).
Guidelines for Head

The Groupe European de Curietherapie and

European Society for Therapeutic Radiology and
Oncology (GEC-ESTRO) for Head and Neck
Cancer have defined standards for head and neck
brachytherapy. These standards have been
adopted by the American Brachytherapy Society
(ABS) as well [101].
The stated aims of head and neck brachytherapy are to control cancer, preserve structure and
function, and achieve a good cosmetic outcome.
High doses are delivered to the target relative to
normal tissue without target motion problems
associated with EBRT [102]. The use of shields
and spacers to protect the mandible and other
structures enhances the therapeutic index. The
current data indicate that, for early oral cavity
cancer (T1T2 N0), brachytherapy is comparable
to surgery, and it is preferable to EBRT or EBRT
with brachytherapy [2]. Doses of 6570 Gy LDR
(or HDR equivalent) at dose rates between 0.3
and 0.6 Gy/h are recommended. For more
advanced lesions, brachytherapy is used as a
boost combined with EBRT to the primary and
lymph nodes. Surgery may be used for any of
these lesions. For larger T2, T3, and T4N0
tumors, post-elective neck dissection radiation
therapy may be indicated. Planned surgery and
postoperative radiation therapy are indicated for
N+ disease. Surgery is preferred for lesions
within 0.5 cm of the mandible or that involve
bone. For oropharyngeal cancer, EBRT and
brachytherapy appears to result in better functional and quality of life outcomes compared to
surgery and postoperative radiation therapy [28
30]. The relative efficacy of brachytherapy and
EBRT to EBRT alone (with or without chemo-
96
Fig. 22 Transcutaneous implantation of recurrent neck

disease in a previously operated patient who had had a
deltopectoral wound closure
therapy) has not been systematically studied for

cancer of the oropharynx. The management of
neck in oropharynx cancer usually involves
EBRT, surgery with EBRT, or brachytherapy for
gross adenopathy. The impact and significance of
HPV-associated head and neck cancer were not
available in 2009 when the GEC-ESTRO guidelines were written.
The brachytherapy clinical target volume
(CTV) is the gross tumor volume (GTV) plus a
0.51.0 cm margin. The planning target volume
equals the clinical target volume (CTV = PTV).
Concomitant chemotherapy with brachytherapy
is not recommended except perhaps in the salvage setting [103, 104]. Completion of the radiation within 8 weeks is advised by GEC-ESTRO,
but after chemoradiation, it often takes more than
2 weeks for recovery of mucous membranes. In
the authors experience, a 910-week time frame
is a more realistic goal. It has been suggested that
there be two brachytherapy competent persons
present in the operating room for implant procedures; however, this may be impractical.
Brachytherapy catheters should be placed parallel with spacing of 11.5 cm (up to 2 cm with
large implants). The author agrees with this recommendation but would add that implant orientation can be complex and variable in head and
neck cancer, so not all catheters will necessarily
be inserted in uniformly parallel rows. The basic
concept is that the lesion should be fully encom-
D.J. Demanes
passed in all dimensions. Image guidance (ultrasound, fluoroscopy, or 3D scanning) is encouraged

where technically feasible. Management of tight
curves with HDR afterloading requires methods
such as dual catheter and button technique [62].
Simulation and dosimetry have evolved from
older 2D systems (New York, Quimby as modified by Henschke and Hilaris et al.; Manchester,
Paterson-Parker; and Paris, Pierquin-Chassagne)
to 3D simulation and computerized dosimetry [7,
8, 10, 13]. Three-dimensional dose volume histogram (DVH) analysis allows in-depth analysis of
tumor and normal tissue dosimetry. The specific
dose optimization method should be specified in
the treatment planning documentation. The GECESTRO brachytherapy quality parameters are
dose nonuniformity ratio (DNR), homogeneity
index (HI), and uniformity index (UI). The
reporting recommendations (ICRU 58) are to
describe the implant technique, source specifications (air kerma rate and total dose), and timedose patterns [105]. Brachytherapy physics
descriptors, such as the mean central dose, minimum target dose, and various other doses and
volumes, are described in the report. Any of three
valid source loading and dose rate methods
(LDR, PDR, or HDR) may be employed [106].
The recommended LDR dose rate was between
0.3 and 0.5 Gy/h [107]. The averaged 24 h PDR
dose rate was similarly 0.30.7 Gy/h with consideration given to daytime-only treatment schedules [108, 109]. Recommendations for HDR
fraction size were 34 Gy including twice-daily
treatment [110]. The much used dose schedules
with 6 Gy fractions used in Japan were not
addressed [111].
The patients clinical condition and the stability of the applicator must be regularly monitored. According to GEC-ESTRO, brachytherapy
catheter removal should be done in the OR,
although the nature and location of the implant
may allow nonoperative removal. A follow-up
program was recommended to monitor disease
control and to identify and manage complications. Patient education should include information on expected inflammatory reactions, which
usually peak at 1 week and resolve in 36 weeks.
Preparations should be made for home oral care,
for tracheostomy and catheter entry site wound

care, and for nutritional support (Fig. 23).
6.1
Site-Specic Issues
Lip and Buccal Brachytherapy was preferred

over surgery for lip cancer, except in small superficial lesions (<0.5 cm), where surgery alone may
be curative with a good cosmetic and functional
result [2, 66, 79, 177]. A rigid set of needles is
recommended for lip cancer, but tube and button
techniques were also considered acceptable.
Buccal cancer is similar to lip cancer, but brachytherapy is suboptimal if the lesion extends to deep
into the buccal alveolar sulcus adjacent to bone.
97
Technically, 12 planes of catheters are used with

a mandatory posterior loop in medial and posterior tumors to encompass disease in the intermaxillary commissure. The excellent outcomes for lip
are somewhat better than for buccal mucosa.
Tongue and Floor of Mouth For tongue and
floor of mouth cancer, the plastic tube and button
technique is the most commonly employed technique [2, 18, 110, 116, 224]. The guide gutter
LDR technique can be used for small tongue or
floor of mouth tumors, especially for older or
infirm patients who are anesthesia risks, because
it can be done under local anesthesia [64]. Tissue
expanders or lead shielding should be used to
protect the mandible.
Fig. 23 (a, b) Dosimetry of a complex interstitial implant of tongue and upper neck adenopathy
98
Brachytherapy alone is the treatment of

choice for T12 N0 tongue cancer and T12 N0
floor of mouth cancer if lesions are <3 cm and
>0.5 cm from the mandible. The relative risk of
normal tissue injury is greater in the floor of
mouth. Since surgery is commonly utilized for
tongue cancer, there is a role for postoperative
brachytherapy when pathology margins are
close or positive. Surgery is the treatment of
choice for floor of mouth cancer that is <0.5 cm
from bone. To decrease risk of bone injury, the
brachytherapy catheters should run parallel to
the contour of the mandible at some distance
(0.5 cm) and thereby avoid excessive doses to
the mandible.
In T3T4 or N+ lesions, surgery and postoperative EBRT with or without brachytherapy or
combined EBRT and brachytherapy may be used.
Relative contraindications to brachytherapy are
T4 tumors involving bone or the inability to
encompass the lesion with catheters. Postoperative
brachytherapy should be considered for close or
positive margins. External beam would be used
for positive lymph nodes or in cases with extensive bone involvement. Patients with extensive
floor of mouth cancer who are not surgical candidates can be treated with brachytherapy (with
EBRT), but only if bone involvement is limited.
Doses for definitive and postoperative treatment are given in Table 1. Postoperative treatment to these structures should be somewhat less
than definitive treatment. The exact dose may
vary with the clinical circumstances (close versus
microscopic versus grossly positive margins).
Lymph Nodes Nodes are either managed by
active surveillance for T1N0 (small T2) or by
planned surgery or radiation therapy or by both
modalities for more extensive disease. The location of lymph nodes at risk are site specific, but
doses are in the range of 5060 Gy for N0 necks
and higher under other circumstances. Salvage
brachytherapy in previously irradiated patients
for oral cavity tumors may be treated with
approximately LDR equivalent to 6065 Gy.
Complications are mainly soft tissue necrosis
(STN) within the volume of the implant and
D.J. Demanes
bone injury (BI) (descried variously and progressively up through bone necrosis requiring
surgery). The previous rates of bone necrosis
listed in Table 1 are probably higher than
expected using modern techniques. Bone injury
can be prevented with proper tissue displacement, shielding, good dental management, and
the use of dwell time adjustments with HDR
brachytherapy. In most cases, the STN or BI
heals with conservative measures, which may
include hyperbaric oxygen treatment. Surgery is
required in <5 % of cases depending upon the
lesion and clinical circumstances. Mandible
reconstruction is a rarely needed and morbid
intervention after EBRT. It may be less so after
brachytherapy alone [2, 25, 117, 118].
Pharynx Treatment of lesions in the oropharynx must include assessment and treatment of
the lymphatics, which are involved in a large
proportion of patients [2, 2830, 102, 110, 116].
Management of gross adenopathy after 4550 Gy
EBRT for microscopic disease (author suggests
5560 Gy in cases with extensive adenopathy)
may consist of more EBRT, brachytherapy, or
surgery. GEC-ESTRO indicates that lesions up
to 5 cm can be treated (but the author believes
such a limit is conservative). They also exclude
lesions of the retromolar trigone, larynx, hypopharynx, and widespread adenopathy or those
that involve the bone. Tracheostomy is apparently used somewhat more conservatively in
Europe than in the authors practice. It is applied
if the vallecula is invaded by a large tumor.
Mandibular protection is used if the lesion
extends into the oral cavity. The implant margin
is larger in oropharynx (>1 cm) than oral cavity
due to the nature of the disease, lower accessibility of the lesion, and difficulties with delineation
of the gross disease. The implant for base of
tongue may include the entire structure if there is
uncertainty about the extent of disease. Suggested
doses (LDR equivalent) for a generous CTV are
2025 Gy (total 7075 Gy), and the GTV is
given a boost to 3035 Gy (total 8085 Gy).
Selected cases (mostly tonsil) with exophytic
T1N0 lesion might be treated with brachytherapy
alone.
99
Table 1 GEC-ESTRO site specific recommendations

Primary site
Lip [2,
112114]
BT alone
<5 cm
Buccal [2, 70,

115]
Oral tongue [2,
25, 117, 118]
T1-2 N0
T1-2 N0
Floor of mouth
[2, 118]
T1-2 N0
<3 cm
Oropharynx
[2, 2830, 102,
110, 116]
Nasopharynx
[2, 119]
Paranasal Sinus
[120124]
T1N0
highly
selected
NR
Salvage [36,
103, 104, 125]
Common
T1
(Small T2)
BT Dose as LDR equivalent

BT + EBRT (lower dose if postoperative)
>5 cm
BT only T1 6065 Gy
T2 6570 Gy
T3 75 + Gy
T3
BT only T1-2 6570 Gy
EBRT 4550 Gy + BT 2530 Gy
T3-4
BT only 6570 Gy
Or Postop EBRT 5060 Gy + BT
1025 Gy
T2 > 3 cm, BT only 65Gy
T3-4 N0
Or Postoperative as above
T1-4 N+
EBRT 4550 Gy
<5 cm
+ BT 25-30Gy Tonsil/30-35Gy
BOT
T1-2
T1 EBRT 60 + HDR 3Gy x 6
T2 EBRT 70 + HDR 3Gy x6
T2-4
EBRT 40-50Gy + BT (tentative
recommendation)
BT only for margins
Variable
BT only 5060 + Gy
Local control
9095 % T1-2 BT
alone
T3 not given
8090 % BT alone
STN or BI
210 %
STN
90 % T1-2 BT
alone
Lower with
BT + EBRT
90 % BT alone
Postop similar
1020 %
STN
510 % BI
<10 % STN
T1-2 8090 %
BT + EBRT
T3-4 6580 %
90 % EBRT + BT
1030 %
STN
510 % BI
2025 %
STN
Low rate BI
NR
NR
NR
5070 % BT alone,
but highly variable
525 %
The data in the tables are given either explicitly as provided in the references or they are the best estimates based upon
the authors interpretation of the article
n number of patients in study, Prim primary tumor or mucosal site, Rec recurrent cancer, Persist persistent cancer, LC
local control, LRC local & regional control, Mo. f/u months follow up, LR local recurrence, RR regional recurrence, DM
distant metastasis, CSS cause specific survival, DFS disease free survival, OS overall survival, OC oral cavity, OT oral
tongue, FOM floor of mouth, RMT retromolar trigone, BA bucco-alveolar, OP oropharynx, BOT base of tongue, SP soft
palate, T tonsil, NPC nasopharynx, LN lymph node, N+ node positive, %LN only cases of neck disease without primary
site recurrence, BT brachytherapy, EBRT external beam radiation therapy, chemo chemotherapy, S surgery, SS surgical
salvage, CT computer tomography, MRI magnetic resonance imaging, Gy Grey radiation dose unit, LDR low dose rate,
MDR medium dose rate, HDR high dose rate, PDR pulsed dose rate, LDR eq. LDR equivalent dose comparable to HDR
dose, NR not reported, STN soft tissue necrosis (ranges from superficial ulceration to deep necrosis), BI bone injury
(ranges from simple exposure to necrosis, which in most instances does not involve surgical intervention),BN bone
necrosis, Tx sites treatment sites, fx fraction(s), IS interstitial, IC intracavitary, NS not significant, Grp group, f/u follow
up, Est. estimate (by author)
Nasopharynx Almost all patients with nasopharynx cancer are treated with EBRT and chemotherapy [2, 30, 119]. The nasopharynx presents access
challenges but brachytherapy may still have a
favorable impact. GEC-ESTRO suggests that only
endocavitary brachytherapy can be performed (the
author does not entirely agree, as noted above).
Since the target depth is limited to <1.0 cm, they
point out that endocavitary brachytherapy is most
suitable for tumors with limited depth of invasion
or those with good response to chemoradiation
therapy. Relative contraindications are bone
involvement, deep invasion into the infratemporal
fossa or nasal cavity, or intracranial extension. The

applicators should be properly fitted and standardized (e.g., Rotterdam), or a custom mold can be
constructed. Since GTV definition can be challenging, a large safety margin is recommended.
Dosimetry with the Rotterdam method was originally based upon 2D orthogonal films and dose
points at 0.51.0 cm deep to bony anatomy. Such
approaches have given way to CT-based dosimetry. When brachytherapy is applied with the
Rotterdam applicator, recommended doses are T1
EBRT 60 Gy plus 18 Gy in 6 fractions in 3 days
and T2+ 70 Gy plus 12 Gy in 4 fractions in 2 days.
D.J. Demanes
100
More recently, stereotactic radiation has been used

to boost T3T4 disease. In the context of salvage
radiation with brachytherapy, dose in the range of
60+ Gy (LDR equivalent) is delivered in approximately 67 days.
Nasal Cavity and Paranasal Sinus Nasal cavity and paranasal sinus cancer is an uncommon
but challenging, cancer [8688, 119, 198]. It typically presents as locally advanced disease without
lymph node metastasis. External beam may be
given before or after surgery, but surgery is the
primary treatment. At the time of surgery, a cavity
may be developed into which a brachytherapy
device may be fitted for dose escalation in tumors
where local control is problematic. Combined
surgery and radiation therapy (including brachytherapy) offer the possibility of organ and functional preservation in stages I and II and in some
stage III tumors with orbital invasion.
Brachytherapy alone may be used for smaller
lesions after surgery if surgical margins are in
question, there is no proximal perineural invasion, and the sites at risk are accessible. It can also
be used for recurrent disease either alone, with
surgery, or with EBRT depending upon the clinical circumstances. Earlier LDR techniques consisted of packing of sinuses with radiation sources
after surgery. In the modern era, molds with
embedded brachytherapy catheters can be custom
fitted and afterloaded using HDR techniques.
Target definition should be based upon 3D imaging and surgical pathologic findings. More data
are needed for unequivocal dose recommendations. At least one study favors EBRT with
brachytherapy over EBRT alone and specifically
noted reduced side effects with selected subtotal
sinus treatment volumes. Although bony confines
make interstitial brachytherapy difficult, there is
evidence to suggest a role for interstitial implants
to improve disease control and better preserve
visual function.
6.2
Salvage
Brachytherapy has been extensively used for salvage of previously irradiated cancers of the head
and neck [36, 103, 104, 125]. The surgical option

should always be considered as well, and treatment recommendations should always be made
in a multidisciplinary setting. Salvage implants
can be complex and potentially morbid. Doses
are usually in the range of 5060+ Gy LDR
equivalent. HDR fraction size recommended by
GEC-ESTRO is limited to 4.5 Gy (slightly higher
than mentioned above). The author notes that
such fraction sizes mean that the radiation course
must be on the order of 10 fractions, which means
the patient must have the implant catheters in
place sometimes more than 1 week. Larger fraction sizes may be a practical necessity.
ABS Recommendations
for High Dose Rate Head
The ABS indicated that HDR could be used alone

or with EBRT with similar indications as
LDR. HDR has radiation safety benefits for unrestricted nursing care and the technical advantage
of dose optimization. It is also conveniently
adapted for intracavitary brachytherapy as a safe
radiation outpatient procedure. The brachytherapy applicator insertions are the same for HDR as
LDR except that looping catheters with acute
angles may obstruct passage of the HDR source
and are generally not recommended for HDR
application. The ABS recommended against concomitant chemotherapy during brachytherapy but
indicated that it can be given during the EBRT
portion of the treatment.
Treatment parameters for HDR are similar to
LDR except dose per fraction and total dose are
different. There is also greater opportunity to
control dose distributions with HDR than LDR
through dwell time modification. Tip and other
dwell times can be adjusted to optimize the isodose distributions for the desired CTV coverage,
dose uniformity, and OAR dose constraints. HDR
may be delivered twice daily with 6 h between
fractions, but it is not always practical (or necessary) to meet this recommendation. The author
considers 4 hours an absolute minimum. The skin
and normal tissue dose should always be lower
than the tumor dose except when the normal

structure is involved with tumor.
HDR brachytherapy can be done in conjunction with surgery to take advantage of tumor
resection and exposure of tissues at risk for
residual disease. One approach is to lay the catheters in the open wound, close, and then allow
one or more days for wound healing before starting treatment delivery. The advantage of this
approach is to allow time for wound healing to
begin, to gain access to pathological data, to utilize 3D image-based dosimetry, and to allow
fractionation. Another option is to do intraoperative radiation therapy (IORT) with brachytherapy in a single fraction. It can be done with
HDR, if the operating room is properly shielded,
or more recently (the author notes), it can be
done with a low-energy electronic radiation
source, which can be done in most standard
operating rooms. Both methods require radiation
safety protocols and proper attention to treatment delivery details since large doses of radiation are applied in just a few sessions. The
electronic source has significant functional limitations for head and neck applications because
of the relatively large source size, the restricted
number of channels, and the limited source path
length.
Recommendations for the use of HDR in oral
cavity cancer are similar to LDR. In HDR, monotherapy should be used for early stage, and combined therapy is used for more extensive disease.
HDR results for oropharynx are also similar to
LDR. The ABS recommended a typical course
consists of EBRT 4550 and 710 fractions of
3 Gy or 46 fractions of 4 Gy. Higher doses were
recommended for larger tumors. Recommendations
for the use of brachytherapy in various forms for
nasopharyngeal cancers were based upon local
control rates of >90 % [181186]. HDR-IORT for
paranasal sinus tumors has been developed in the
context of an operating room shielded for HDR. It
is most successful in cases where gross tumor has
been completely resected [126].
HDR can also be used as salvage therapy in
previously irradiated cases. Recurrences are generally better prevented than treated, so it is recommended that brachytherapy be considered as part
101
of the initial treatment strategy. A complete restaging workup is needed, and the physicians should
be aware of and notify the patients that complication risks are increased over primary treatment
especially with prior surgery, skin involvement,
deep necrosis, or bone exposure. Larger margins
(clinical treatment volumes) are advisable, particularly if no EBRT is planned. A review of previous
radiation doses and fields will help guide treatment planning. It is difficult to make specific fraction recommendations, but doses of 5060 Gy
LDR equivalent were suggested. A summary of
the GEC-ESTRO and ABS site-specific recommendations can be found in Table 2.
Quality and Reporting

Standards for Head and
Neck Brachytherapy
These recommendations are based, in part, on the

American College of Radiology Guidelines and
Technical Standards for Brachytherapy, 2008
[127].
8.1
Pretreatment Standards
Brachytherapy of the head and neck is a complex

multistep process administered by a group of
qualified professionals. The radiation oncologist
and medical physicist must be certified to perform brachytherapy, and the physician must be a
duly authorized to use therapeutic radionuclides.
Dosimetry calculations, treatment delivery, and
nursing persons must be similarly appropriately
qualified. Standards for delivery of head and neck
brachytherapy require a history and physical
examination, review of relevant operations and
pathology reports, and review of imaging studies.
A summary of the consultation should be provided to the patients other physicians. Sitespecific TNM staging must be performed, and a
lesion diagram must be created. The therapeutic
intent (curative, palliative, local tumor control,
etc.) should be established, and treatment options
should be reviewed with the patient. Informed
consent must be obtained and documented. The
D.J. Demanes
102
Table 2 Summary ABS and GEC-ESTRO guidelines
Work up
Imaging
Dental
Mandible shields
Sequence
Antibiotics,
steroids
Techniques
Catheter spacing
Chemotherapy
with BT
Target volumes
Treatment
parameters
Total treatment
course
HDR fraction size
Oral cavity
T1-2 N0
Oral cavity T3-4 or
N+
Oropharynx
Nasopharynx
Intracavitary
Nasal and
paranasal
Salvage
H&P, endoscopy, biopsy

CT, MRI, PET-CT
Pretreatment evaluation and
follow up
Oral cavity/lip or other sites as
needed
EBRT then BT (GEC-ESTRO),
ABS not stated
Optional (antibiotics always
used by author)
Tube and button, guide gutter,
intracavitary applicators
1.01.5 cm
No except salvage (preferably
neoadjuvant or adjuvant)
CTV = PTV (see references for
discussion of target volumes)
DVH, DHI, CTV, and OAR
3.
4.
5.
6.
7.
8.
Imaging study reports in chart

Relevant operative reports in chart
Lesion diagram
AJCC (or comparable) staging
Current medication list (including allergies)
Preoperative assessment should include:
(a) Preoperative medical evaluation for anesthesia according to patient needs and
facility standards
(b) Evaluation of recent smoking and drinking history
(c) Assessment of bleeding risk, history of
DVT, or anticoagulation
(d) Physical examination
(e) Results of recent EKG, CXR, basic blood
counts, and chemistry panel
<8 weeks (<9 weeks chemo)
8.3
Brachytherapy Treatment
Planning
34 Gy (max 4.5 Gy) These

fractions sizes are not always
practical
LDR equivalent 6070 Gy BT
only
EBRT 4560 Gy + HDR
2530 Gy (consider surgery and
postop EBRT + BT)
EBRT 4560 Gy + HDR
2030 Gy
T1 EBRT 60 + 3Gy 6,
T2 + EBRT 70 Gy + 4 Gy 3
EBRT 4550 Gy + BT or IORT
(doses not standardized)
BT usually interstitial EqD2
5060 Gy
Planning consists of determination of the type and

extent of the procedure. The risk to the airway and
the risk of vascular injury and bleeding associated
with the procedure are of primary interest. A plan
for intubation and airway management is coordinated with anesthesia, and standardized preoperative and postoperative order sets are recommended.
Coordination with the nursing staff and arrangements for radiation safety on the wards is required.
The use of remote afterloading has markedly
improved the ability of nurses to care for head and
neck brachytherapy patients.
See Table 1 for abbreviations
8.4
need for tracheostomy and special medical needs
related to the implant should be coordinated with
anesthesia and head and neck surgeons and other
physicians in advance of the procedure.
8.2
Preoperative Brachytherapy
Checklist
1. Consultation sent to referring physicians

2. Pathology documentation in chart
The Procedure, Prescription,

and Treatment Delivery
The applicator insertion is done in the operating

room or another appropriately prepared procedure room. Simulation radiography is subsequently required to obtain an image dataset of
the relationship of the applicator to the target
and normal anatomy. The image dataset is
imported into the treatment planning system
(TPS). The radiation oncologist must provide a
written, signed, and dated prescription before
treatment planning commences [128]. It must

designate:
HDR brachytherapy: patient name, the radionuclide, treatment site, dose per fraction, number
of fractions, and total dose
LDR brachytherapy: treatment site, the radionuclide, and dose (before implantation) and
(after implantation but before completion of
the procedure) the radionuclide, treatment
site, number of sources, and total source
strength and exposure time or total dose
The physician contours the CTV (GTV) and
organs at risk (OAR) on the CT images. The 3D
locations of the brachytherapy catheters are digitized and reconstructed in the TPS. The medical
physicist or supervised dosimetrist performs
dosimetry calculations on the treatment planning
computer and generates a dose volume histogram, target coverage (isodose volumes), and
dose uniformity parameters. Dose optimization
techniques should be described and, if possible,
target coverage and OAR dose constraint parameters should be delineated. An independent
dosimetry verification calculation must be performed to confirm the primary dosimetry
calculations. The physicist and physician check
the plan parameters, target coverage, and OAR
dose constraints to ensure they are satisfactory
and that the treatment meets the objectives of the
written directive. Hardware such as HDR source
transfer tube connections are made and verified
by the radiation therapist, physicist, and
physician.
Brachytherapy delivery can be manual or
robotic and HDR or LDR, but it must be monitored and properly documented, along with any
modifications during the course of treatment.
Permanent seed applications should be in
accordance with all standards set forth for permanent seed brachytherapy [129]. Patients
with permanent seed implants should be provided with written descriptions of the home
radiation protection guidelines. The medical
physicist and radiation safety officer design
institutional brachytherapy safety guidelines,
103
consistent with governmental regulations for

brachytherapy.
8.5
Treatment Monitoring
The radiation oncologist should regularly evaluate the patient during treatment. The applicator
should be checked for position accuracy and stability. The patients medical condition (vital
signs, nutritional status, airway, wound condition,
urine output, laboratory results, medications, etc.)
should be reviewed and adjusted daily or more
often as needed. Due to radiation safety consideration, HDR (and PDR) facilitates the care of head
and neck brachytherapy patients who typically
require frequent and close nursing attention.
Plans should be made for implant removal either
on the ward under controlled conditions (sitting
up, good suction, preparation for airway problems and bleeding) or in the operating room. It is
advisable to have an emergency tracheostomy
tray at the bedside in some cases. Removal of the
implant in the operating room requires preparations for anesthesia (i.e., nothing by mouth, consent, laboratory determinations, etc.). Operating
room removal facilitates airway control, management of bleeding, and patient comfort.
8.6
Treatment Summary
At the completion of LDR brachytherapy and

after each HDR fraction, a radiation safety survey
should be performed. A written summary of the
treatment delivery parameters should include
description of:
1. Total brachytherapy dose
2. Brachytherapy dates
3. Total radiation dose including EBRT, if it was
administered
4. Technique (intracavitary, interstitial)
5. Target volume
6. Clinical course during treatment
7. Disposition (source accounting, follow-up plan,
coordination with chemoradiation physicians)
D.J. Demanes
104
8.7
Follow-Up
A follow-up plan should be made to assess disease control and to manage side effects. The radiation oncologist should routinely see the patient
at 12-week and then at 24-week intervals for
3 months. Subsequent follow-up may vary from
case to case; it should be carefully coordinated
with other physicians to monitor disease, manage
reactions and complications, guide nutritional
support, and encourage regular dental care.
Monthly physician visits are reasonable for the
first year and thereafter at regular intervals as
indicated by the individual patient needs and
circumstances.
8.8
Program Requirements
Brachytherapy supplies, equipment, and devices

are diverse, complex, and often unfamiliar to
most medical personnel. Prior to taking the
patient to the operating room, the needles, catheters, templates, and other brachytherapy supplies
must be checked for availability and for proper
preparation. Ward facility arrangements are necessary for LDR applications. Admission to the
intensive care unit is recommended whenever
there is a fresh tracheostomy, if re-intubation
might be difficult, or in cases with significant
comorbid conditions. The author recommends
liberal use of intensive care units in the management of head and neck brachytherapy patients.
A physics quality assurance program with
regularly scheduled inspections, testing, and
maintenance of the technical devices such as simulators, survey monitors, and the remote afterloader is required. Treatment planning computers
must be up to date and in good working order.
Standards for dosimetry, treatment delivery, and
brachytherapy documentation must be set and
maintained. Routine leak testing of all sealed
sources is required by regulatory agencies, and
the radiation safety officer must create and supervise a radiation safety and personnel protection
program. The radiation oncologist and medical
physicist must have a system to independently
verify brachytherapy parameters such as source
model, radionuclide type, source strength, dose

rate, total dose, and treatment duration.
Continuing education of the brachytherapy team
and hospital personnel who work with radionuclides is also required.
8.9
HDR Remote Afterloading
Prior to each treatment, the medical physicist or

radiation oncologist should verify the correctness
of connections of the source transfer tubes from
the HDR afterloader to the applicator. The medical physicist must verify that the treatment
parameters at the HDR console correspond to
those created at the treatment planning computer.
Source decay calculations must be performed for
each and every treatment delivery. Independent
verifications of physics and dosimetry parameters (prescription, fraction number, current activity or air kerma strength, decay-corrected
radiation time, total reference air kerma (TRAK),
and indexer length) just prior to source insertion
are essential for HDR brachytherapy. Applicator
position and integrity should also be verified just
before each HDR fraction.
The radiation therapist and nurses perform
auditory, visual, and vital status monitoring
throughout treatment. The radiation oncologist
and medical physicist must supervise HDR
afterloading and prepare for emergency procedures. The progress of treatment is displayed
and followed on the HDR remote afterloading
treatment console. At the end of treatment, a
radiation survey is performed to confirm that the
radiation source has been safely retracted into
the afterloading device. A brachytherapy charting system specifically designed for HDR clinical management and for continuing medical
physics should be employed. It should record
target dose, dose per fraction, date and time of
delivery, and normal tissue dose monitoring.
Special physics evaluation before or during
treatment may be used to evaluate or coordinate
prior external beam or other complexities that
may impact decisions about the current HDR
brachytherapy program or affect the patient in
any meaningful way.
Results
9.1
How to Read Tables

(Tables 3, 4, 5, 6, 7, 8, and 9)
A review of the literature was performed, and

summary tables were created. Studies published
after 1985 were selected, if they had at least 20
cases and at least two years of follow up. The
results of brachytherapy alone or in combination
with EBRT are presented. They are divided into
(1) LDR oral cavity and oropharynx, (2) HDR
oral cavity and oropharynx, (3) LDR versus HDR
oral cavity and oropharynx, (4) lip and buccal
mucosa, (5) nasal cavity and paranasal sinus, (6)
nasopharynx, and (7) salvage brachytherapy. The
T-stages or stage groupings are presented (for N0
cases stage I = T1 and stage II = T2), and the
percentage of cases with positive lymph nodes
are described as %N+. The table specifies
whether brachytherapy was used alone or with
EBRT. Median follow-up times are provided for
each study. Outcomes (ranging from 2 to 5 years)
are described in terms of local control (LC) at the
primary site, regional control (RC), or
locoregional control (LRC). Management of the
neck (observation or planned neck dissection) is
presented, and RC with and without surgical salvage is given if the information was available.
Survival is presented as disease-free survival
(DFS), cause-specific survival (CSS), or overall
survival (OS). The morbidity grading systems
were too varied to attempt a direct tabular comparison. Complications are categorized as soft
tissue necrosis (STN) and bone injury (BI). The
severity and duration of STN and BI were sometimes difficult to gauge. Transient STN of limited
severity (grade 1) may or may not have been
included or described in the articles. Bone injury
may also have ranged from simple bone exposure
to frank osteonecrosis, but most reports suggest
that only a small fraction of cases of BI required
major surgical intervention. Other less common
complications such as cranial neuropathies are
not listed, and there was insufficient information
about speech, swallowing, oral dryness, or taste
acuity to describe them. The outcomes with
brachytherapy are, for the most part, published
105
before the epidemic of HPV or knowledge of its

prognostic significance. References are listed in
the tables.
9.2
Oral Cavity Low Dose Rate
The largest experience with LDR brachytherapy

comes from Europe and Asia. Early reports
describe the use of radium-226 or cesium-137
needles, and a few centers used radium-222 or
gold-198 permanent seeds. Iridium-192,
iodine-125, and palladium-103 became the standard in the 1980s. The outcomes for LDR brachytherapy of the oral cavity fall into two categories:
those that are done after surgery for close or positive margins (shaded in the table) and those that
are done primarily.
Numerous studies address the use of brachytherapy alone versus those used in combination
with EBRT for T1T2 N0 cancers of the oral cavity or the floor of the mouth. The uniform conclusion is that brachytherapy alone provides higher
control rates and fewer complications than when
used with EBRT. Doses for brachytherapy alone
are 6070 Gy. When brachytherapy is used as a
boost, the does is more variable because EBRT
doses ranged from 30 to 60 Gy. The brachytherapy dose administered with 4550 Gy EBRT was
typically 2030 Gy. Local control rates are
8090 % for T1 and 7080 % for T2 with a reasonable expectation for surgical salvage at the
primary site for isolated recurrences. Management
of the neck was frequently expectant where
regional control was about 75 % without surgery
and 8090 % with surgery or surgical salvage or
radiation therapy to the neck. It is doubtful if
neck dissection or external beam irradiation is
routinely required for favorable T1N0 or small
T2N0 cancers of the oral cavity. Surgical salvage
of isolated neck recurrence with or without radiation is successful in more than half of the cases
depending upon the extent of disease.
Simultaneous failure of the neck and primary is
more ominous. Cause-specific survival approximates an LRC of 7080 % because few patients
have distant metastasis without persistent disease
in the head and neck region. Overall survival is
Primary
OT
OT
OT
OT
65 % OT
35 % FOM
n
168
95
130
147
274
Author
Mazeron
1990 France
[74]
Wendt 1990
USA [131]
Hareyama
1993 Japan
[132]
Pernot 1992
France [133]
Simon 1993
France [65]
49 % T1
52 % T2
9 % N+
T2N0
68 % T1-2
32 % T3
24 % N+
18 % T1N0
82%T2N0
Stage
45 % T1
55 % T2
8 % N+
None
2050 Gy
Prim
3650 Gy
LN
52 % EBRT
40 Gy
(1050)
24 % EBRT
19 % No
EBRT
EBRT
Variable
EBRT dose
None
6070 Gy
BT only
5879 Gy
BT only
31 Gy
EBRT + BT
52170 Gy
BT only
3096 Gy
EBRT + BT
2055 Gy
depending
on EBRT
dose
35
36
60
159
Mo.
LDR BT dose f/u
6070 Gy
120
51 % LC
EBRT + BT
90 % LC
BT alone
47 % LRC
EBRT + BT
68 % LRC
BT alone
88 % LC T1
84 % LC T2
82 % OT, 86 %
FOM
9194 %
T1-2 LC
71 % T3 LC
LC, RC, LRC

25 years
78 % LC
60 Gy
90 % 65 Gy
94 % 70 Gy
79 % RC N0
6492 % LC
5693 % RC
Table 3 Low dose rate (LDR) brachytherapy oral cavity and oropharynx (bolded) no prior irradiation
23 %
5%
NR
22 %
51 % BT alone
11 % BT
33 % EBRT + BT 12 %
EBRT
+ BT
6585 %
Stage I/II
40 % Stage
III/IV
Est 50 % DFS
Est 75 % with
SS
Overall survival
25 years
STN
52 % T1N0
16 % T1
44 % T2N0
28 % T2
8 % T1-2 N1-3
22 %
1%
13 %
10 %
BI
12 %
77 % guide gutter/23 %
plastic tubes
More complications if
source spacing >15 mm
(FOM > OT)
Neck management not
stated
91 % Ra-226 needles
LC better with BT (also
high surgical salvage)
RC better with more
EBRT
Cs-137 needles
Neck surgery in N+
cases only (OS 52 %)
Neck SS 39 % (OS 56 %)
Mandibular complications
doubled with EBRT
21 % neck dissection
Increased complications
in BT alone
if dose >75 Gy
Comments
N+: 23 % EBRT alone,
77 % neck surgery + EBRT
106
D.J. Demanes
48 % T1-2
13 % T3-4
14 % N+
7 % T1-4
2 % N+
20 % T1-2
12 % T3-4
14 % N+
47 % OT
50 % FOM
3%
Gingiva
OC
OT
OC
Postop OC
OP
97
27
55
1344
Pernot 1995
France [136]
Takeda 1996
Japan [137]
Chao 1996
USA [138]
Pernot 1996
France [18]
35 % pT1
65 % pT2
18 % N+
65 %
pT1-T2
31 %
pT3-T4
23 % N+
8 % T1N0
80 % T2N0
12 % T3N0
OT
FOM
94
Stage
24 % T1N0
53 % T2aN0
23 % T2bN0
55 % T1N0
45 % T2N0
Primary
OT
n
370
Author
Shibuya
1993 Japan
[134]
Bachaud
1994 France
[135]
57 Gy
(1860) BT
only
26 Gy
EBRT + BT
5894 Gy
66 Gy
(6070) BT
only
26 Gy
EBRT + BT
NR
60
48
>24
NR
44
Mo.
LDR BT dose f/u
7095 Gy
24
only
288
6075 BT
only
2030
BT + EBRT
NR
5060 Gy
BT only
1015 Gy
EBRT + BT
4060 Gy
6075 BT
96 % EBRT only
2030
EBRT + BT
5569 Gy
EBRT
50 Gy
(1550) +
BT
94 % EBRT
4050 Gy
54 % EBRT
60 % EBRT
1542.5 Gy
Dose NR
53 % EBRT
EBRT dose
27 Gy
(2040)
19 % EBRT
48 Gy
(4554)
72 % EBRT
4694 % LC
4389 & LRC
90 LC
80 % LRC
82 % LC
EBRT
77 % LC
EBRT + BT
67 % LC BT
alone
5097 % LC
3885 % LRC
73 % LC (89 %
with SS)
63 % RC (96 %
with SS)
89 % LC
82 % LRC
75 % LC T1
51 % LC T2
LC, RC, LRC

25 years
85 % LC
2765 %
2788 % CSS
67 %
74 % CSS
2971 %
2888 % CSS
68 %
70 % DFS
82 %
67 %
74 % CSS
NR
25 %
30 %
6%
a
Overall survival
25 years
STN
84 % T1
3%
78 % T2a
72 % T2b
43 %
3%
45 % DFS
NR
0%
30 %
5%
3%
BI
8%
(continued)
Au198 mold technique

with EBRT for lesions
>5 mm thick
10 % underwent surgery
for BN
Assume all cases N0
not specified
Postop BT for close or
positive margins
71 % EBRT alone, 29 %
neck surgery
13 BT + EBRT + 3 BT
only (positive margins)
Results given as a range
of OC and OP sub-sites
Better outcome with BT
only T1-2 N0
Some cases received
EBRT to LNs
Complications:
9 % Grade 2 and 3 %
Grade 3 (slightly higher
for postop BT)
Postop BT EBRT for

close or positive margins
Comments
Same BT dose when
EBRT given
9 % chemo
No surgery
No chemo

107
Primary
OT
OT
Various
OT <40
y/o
62 % OC
28 % OP
10 %
Other
n
254
173
29
70
236
Author
Yamazaki
1997 Japan
[139]
Matsuura
1998 Japan
[140]
Beitler 1998
USA [95]
Yoshida
1999 Japan
[141]
Grabenbauer
2001
Germany
[142]
Table 3 (continued)
42 % Stage
III
58 % Stage
IIIIV
N+ not
specified
T1-2 N0
NR
43 % T1N0
57 % T2N0
Stage
52 % T1N0
48 % T2N0
5060 Gy
75 % EBRT
30 Gy
36 % EBRT
60 Gy
(5065)
30 Gy
(1850)
38 % EBRT
EBRT dose
None
45 Gy
(3690) BT
only
23 Gy
(1426)
EBRT + BT
70 Gy
(5098)
+EBRT
cases total
70 Gy
LDR BT dose
70 Gy (5393)
Ra226
70 Gy
(6285) Ir192
69 Gy
(6084) BT
only
60 Gy
(38136)
EBRT + BT
120160 Gy
I-125 seeds
30
156
26
>24
Mo.
f/u
108
74 % LC
86 % Stage III
62 % Stage
IIIIV
91 % LC T1
71 % LC T2
52 % LRC
T1-2
93 % LC
LC, RC, LRC

25 years
80 % LC T1,
67 % LC T2
75 % RC T1,
58 % RC T2
93 % LC T1
78 % LC T2
85 % RC T1
71 % RC T2
50 %
64 % vs. 39 %
Stage III vs.
IIIIV
62 % CSS
80 % CSS
59 %
84 % T1
69 % T2
9%
4%
10 %
NR
a
Overall survival
25 years
STN
75 % T1,
NR
68 % T2 CSS
9%
28 %
3%
NR
BI
5%

positive margins
23 % developed DM
Various radionuclides
Outcomes same as
4065 y/o, slightly better
LC than >65 y/o
Increase BI only with
EBRT + BT, not with BT
only
Postop BT 77 %, 13 %
chemo, 10 %
hyperthermia
Article does not give
TNM, combines Primary
(74 %) and Recurrent
(26 %) see salvage
Table 9 estimates
OC = OP for OS
(includes 26 % salvage
cases)
Ra226 needles or Ir192

hairpins
T <8 mm thick did better
than 8 mm thick
Comments
No surgery No chemo
Same outcome Ra226 to
Ir192
108
D.J. Demanes
Primary
FOM
OT
45 % OT
55 % FOM
OT
n
160
616
82
279
Author
Marsiglia
2002 Italy
[143]
Nakagawa
2003 Japan
[21]
Lapeyre
2004 France
[25]
Bourgier
2005 France
[22]
T2N0
5 % N+
71 % T1-2
29 % T3-4
23 % N+
28 % T1N0
72 % T2N0
Stage
49 % T1
51 % T2
21 % N+
None
48 Gy
(4052)
56 % EBRT
30 Gy
(1050)
23 % EBRT
EBRT dose
50 Gy
if N+
60 (872)
BT only
60 Gy BT
only
24 Gy
EBRT + BT
70 Gy
(50100) BT
only
45
60
65
Mo.
LDR BT dose f/u
70 Gy
>120
(5880)
77 % CSS
87 % T1,
73 % T2
79 % LC (89 %
with SS)
70 % RC (78 %
with SS)
74 % 2 y
47 % 5 y
NR
NR
NR
Overall survival
25 years
STN
89 % DFS
14 %
90 %LCT1-2pN- 68 %
78 % LC
30 % if N+
T1-2 N+
80 % CSS
80 % LC T3N57 % LC T3N+
86 % LC
(94 % with SS)
62 % RC
LC, RC, LRC

25 years
90 % LC
NR
NR
NR
BI
18 %
(continued)
Comments
Neck dissection T2 or
N1/surveillance in 41 %
(lesions < 3 cm)
SS successful in 50 % of
T or N failures
2.5 % BN required
surgery, 30 % developed
2nd primary
No T surgery, Neck SS
only, No chemo
50 % Cs-137/Ra226
needles and 28 %, Ir192
22 % Au198/Ra222
permanent seeds older
infirm patients
No difference RC
EBRT (20 % R-failures
also had L-failure)
positive margins
Neck surgery 71 %
(28 % pN+)
Neck recurrence 15 %,
second primary 25 %
Morbidity G3 15 % with
BT + EBRT vs. 3 % BT
only
11 % prior H&N cancer
Neck surgery 67 %
(48 % of operated cases
were pN+)
(EBRT neck given in
77 % of pN+)
Morbidity G1 12 %, G2
1.4 %, G3 2.9 % (surgery
needed)

109
Primary
OT
>80 y/o
68 % OT
14 % FOM
17 %
Other
OT
>75 y/o
78 %
Lip-OC
22 % OP
47 %
Tongue
18 % FOM
26 % SP
9 % Tonsil
BOT
n
21
180
127
385
114
70
Author
Yamazaki
2010 Japan
[145]
Yoshimura
2011 Japan
[146]
Khalilur
2011 Japan
[147]
Strnad 2013
Germany
[148]
Stannard
2014 South
Africa [56]
Puthawala
1988 USA
[78]
Table 3 (continued)
26 % T1-2
74 % T3-4
73 % N+
89 % T1-2
11 % T3
11 % N+
91 % T1-2
8 % T3-4
30 % N+
24 % T1N0
76 % T2N0
T1-2 N0
Stage
10 % T1N0
70 % T2N0
20 % T3N0
4550 Gy
100 %
EBRT
50 Gy
(4270)
37 % EBRT
55 Gy
37 % EBRT
None
3040 Gy
Est. <20 %
EBRT
EBRT dose
30 Gy
40 % EBRT
2025 Gy
T1-2
EBRT + BT
30-40 Gy
T3-4
EBRT + BT
59 (2764)
BT only
23 (1030)
EBRT + BT
57 Gy BT
only
24 Gy
EBRT + BT
70 Gy
7090 Gy
79 % LC
56 % LRC
LC, RC, LRC

25 years
91 % LC
84 % RC
60
39
63
83 % LC
77 % LRC
81 % LC
61 % LRC
86 % LC
92 % N0-1 v
74 % N2
24218 86 % LC
63 % RC (75 %
with SS)
26
Mo.
LDR BT dose f/u
3285 Gy
30
67 % DFS
57 %
74 % CSS
69 %
81 % CSS
57 %
74 % CSS
83 %
87 % CSS
6%
18 %
10 %
2%
NR
a
Overall survival
25 years
STN
83 % CSS
10 %
3%
0%
5%
1%
3%
BI
5%
Comments
20 % HDR/80 % various
LDR source
No major BI
Results similar to
younger patients
No chemo, no surgery
(i.e., BT EBRT)
Cs137 or Ir192 IS, some
Au-198, some molds
No correlation
complications and
pre-existing comorbidity
Au198/Rn222
seeds;Ra226/Cs137
needles;Ir192 pins
Mandibular spacers used
Outcomes worse for
patients >80 years old
Pulsed dose rate
BT preceded by surgery
(326/385, 85 %)
3 % had surgery for
complications
I-125 afterloading
(instead of Ir 192)
11 % cases had recurrent
cancer
41 % primary surgery,
15 % neck surgery, 20 %
chemo
No surgery
No Chemo
110
D.J. Demanes
BOT
BOT
BOT
25
20
41
Demanes
2000 USA
[90]
Barrett
2002 USA
[151]
Gibbs 2003
USA [152]
51 % T1-2
49 % T3-4
68 % N+
65 % T1-2
35 % T3-4
85 % N+
52 % T1-2
48 % T3-4
84 % N+
Stage
69 % T1-2
31 % T3-4
86 % N+

a
Overall Survival (OS) unless specified otherwise
Primary
BOT
n
36
Author
Harrison
1992 USA
[149]
50 Gy
(4968)
100 %
EBRT
5054 Gy
100 %
EBRT
54 Gy
(5063)
EBRT dose
5054 Gy
100 %
EBRT
26 Gy
(2030)
EBRT + BT
25 Gy
(2030)
EBRT + BT
1937
EBRT + BT
62
45
55
Mo.
LDR BT dose f/u
2030 Gy
22
EBRT + BT
85 % LC T1-2
79 % LC T3-4
87 % LC
84 % LRC
92 % LC
86 % LRC
LC, RC, LRC

25 years
88 % LC
66 %
79 % CSS
30 %
41 % DFS
36 %
68 % DFS
7%
20 %
4%
a
Overall survival
25 years
STN
88 % 2y
22 %
5%
0%
0%
BI
3%
Comments
N0: 50-54 Gy EBRT to
neck
N+: EBRT
60 Gy + post-RT neck
dissection
22 % chemo
No chemo
No neck surgery
Bone exposure in one
case required soft
tissue graft
4 cases excluded BT
only for re-irradiation
No chemo, 80 % neck
surgery
STN resolved without
major intervention
5 % chemo
Neck surgery 82 %
(of 28 N+ cases)
LC 87 % with SS

111
Primary
OT
OC
OT
61 % OC
39 % OP
OT
OT
n
27
19
71
33
50
17
34
Author
Lau 1996
Canada [159]
Leung 2002
China [76]
Kakimoto
2006 Japan
[130]
Patra 2009
India [61]
Guinot 2010
Spain [75]
Akiyama
2012 Japan
[111]
T1-2 N0
84 % T1-2
16 % T3
32 % N+
79 % T1-2
21 % T3
59 % N+
39 % T1N0
61 %T2N0
53 % T1N0
47 % T2N0
Stage
93 % T1-2 N0
7 % T3N0
None
50 Gy
(4070)
66 %
EBRT
50 Gy
(4666)
100 %
EBRT
None
None
EBRT
dose
None
44 Gy
(4249)
10 fx
18 Gy
(1225)
3Gy/fx
54 Gy
(6 Gy/fx)
(33 %)
60 Gy
(6 Gy/fx)
(67 %)
17.5 Gy
(1421)
33.5Gy/fx
5460 Gy
6Gy/fx
55 Gy
(4564)
5.5 Gy/fx
BT dose
45.5 Gy
6.5 Gy/fx
44
52
44
1840
39
43
Mo.
f/u
36
88 % LC
85 % LC
100 % LC
T1-2
61 % Stage
IIIIV with
SS
91 % LC
T1-2
43 % LC T3
85 % RC
87 % LC
63 % RC
LC, RC, LRC

25 years
53 % LC
(93 % with
SS)
89 % RC with
SS
95 % LC
Table 4 High dose rate (HDR) brachytherapy oral cavity and oropharynx (bolded) no prior irradiation
77 % OS
85 % OS
74 %
DFS
NR
81 %
84 %
CSS
74 %
85 %
CSS
6%
3%
16 %
0%
13 %
5%
Overall
survival
25 years STN
66 %
29 %
92 %
CSS
12 %
9%
4%
0%
14 %
5%
BI
15 %
Matched pair analysis

54 Gy = 60 Gy
RC = 65 % (60Gy) and 47 %
(54 Gy)
Bone exposure not
necrosis
24 % chemo
82 % postoperative RT
100 % LC in BT only cases
Comment
SS successful 11/12 cases
T1-2 with L-recurrence
SS successful 8/11 with RR
3/4 BN with SS). STN 7 G2
and 1 G3
No chemo
7 cases elective neck
dissection
3 cases salvage neck
dissection
2 cases LN+ neck received
postop neck EBRT
72 % single plane implants
65 % successful SS of neck
recurrence EBRT
STN/BI resolved without
surgery except 1 case
6 cases speech and swallow
toxicity (1 PEG)
78 % LRC with surgical
salvage
112
D.J. Demanes
29 % OC 76 % T1-2
71 % OP 24 % T3-4
53 % N+
OP
BOT
BOT
55
82
88
60
Rudoltz 1999
USA [161]
Nose 2004
Japan [60]
Cano 2009
USA [79]
Takacsi-Nagy
2013
Hungary
[162]

11 % T1-2
89 % T3-4
70 % N+
42 % T1-2
58 % T3-4
81 % N+
65 % T1-2
35 % T3-4
51 % N+
71 % T1-2
29 % T3-4
53 % N+
OP
38
Levendag
1997
Netherlands
[33]
36 % T1N0
64 % T2N0
OT
67
Matsumoto
2013 Japan
[160]
62 Gy
(5070)
100 %
EBRT
62
(5070)
100 %
EBRT
46 Gy
83 %
EBRT
55 Gy
(4570)
100 %
EBRT
46 Gy
100 %
EBRT
20 Gy
(838)
51 %
EBRT
17 Gy
(1230)
5 Gy/fx
25 Gy
(1830)
33.5 Gy/fx
21 Gy
(1836)
3.5 Gy/fx
48 Gy
(4854)
6 Gy/fx
17 Gy
(1230)
1.22.5
Gy/fx
Variable
HDR/PDR
Est. 24 Gy
LDR eq.
50 Gy
(4065)
46.5Gy/fx
121
36
26
31
31
59
57 % LC
50 % LRC
82 % LC
80 % LRC
82 % LC
68 % LRC
86 % LRC
SS + EBRT
79 % LC
87 % LC
T1-2
87 % LC
90 % LC
72 % LRC
47 %
61 %
CSS
81 %
70 %
DFS
64 %
88 %
CSS
NR
Est.
60 %
OS
88 %
92 %
CSS
12 %
5%
29 %
9%
NR
22 %
2%
0%
0%
7%
NR
0%
54 % chemo
Successful SS in 5/5 LR and
9/11 RR
STN 7 % grade 2 and 15 %
grade 3
50 % tonsil/50 % soft
palate
6 % BT only
Same outcome tonsil and
soft palate
No chemo
N+ treated with
hyperthermia and EBRT
55 Gy
SS successful in
5/10 L-recurrence
No chemo, 7 % cases Rec
or 2nd Prim
41 N+ Neck
Surgery + 24Gy (1830)
EBRT boost
STN healed 20/24 cases
<12 months
100 % chemo, BT
(11LDR + 77HDR)
SS in 7 cases for
R-recurrence
3 % tracheostomy and
2 % G-tube dependent
28 % chemo (OS 69 % with
vs. 39 % without)
93 % cases Stage IIIIV

113
Lip
Lip
Lip
Lip
Lip
Lip
Lip
248
47
2794
231
237
72
54
Cowen 1990
[163]
Orecchia
1991 [164]
Van
Limbergen
1993 [165]
Farrus 1996
Spain [112]
Conill 2007
Spain [168]
Gerbaulet
1994 [166]
Beauvois
1994 France
[167]
Primary
Lip
n
1896
Author
Mazeron 1984
[114]
61 % T1N0
39 % T2N0
54 % T1N0
19 % T2No
6 % T3N0 and
21 % rec
66 % T1N0
25 % T2N0
6 % T3N0 +
3 % N+
NR
T1-4 and rec T
T1-2
T1-4
Stage
T1-4
LDR
LDR
LDR
LDR
LDR
LDR
LDR
61.5 Gy (6065)
6267 Gy
6568 Gy
7085 Gy
4090 Gy
6080 Gy
6081 Gy
Dose rate Dose

LDR
NR
Table 5 Lip and buccal (bolded) brachytherapy no prior irradiation
NR
72
NR
NR
NR
Mo. f/u
NR
98 %
LRC
89 % LC
95 % LC
91 % RC
90 % LC
Cs137
96 % LC
Ir192
80 % LC
rec cases
94 % LC
94 % LC
LC, RC,
LRC 25
years
89 % LC
Ra/Cs
97 % LC
Ir192
96 % LC
NR
10 %
NR
NR
NR
NR
70 %
0%
100 % DFS
NR
74 %
91 % CCC
NR
NR
NR
NR
Overall
survival 25
years
STN
NR
NR
0%
NR
<1 %
NR
NR
NR
NR
BI
NR
89 % T1N0, 63 %
T2N0 neck observed
and
Surgical salvage LC
99 % RC 94 %
Most STN heal
without complication
in <3 mo
Outcome
comparisons:
initial vs. later cases
and implant quality
BT only
No surgery or EBRT
Comments
In: Gerbaulet A, Potter
R, Mazeron JJ, et al.,
editors. The GECESTRO handbook of
brachytherapy.
Leuven, Belgium:
ACCO; 2002. p.
227236
114
D.J. Demanes
Lip
Lip
Lip
Lip
Lip
Lip
43
161
51
89
32
102
Johansson
2011 Sweden
[169]
Guibert 2011
France [66]
Lock 2011
Canada [98]
Rio 2013
France [170]
Serkies 2013
Poland [171]
Guinot 2014
Spain [113]
29 % T1N0
58 % T2N0
13 % T3-4
53 % T1N0
47 % T2-4
N+ 5 %
90 % T1N0
10 % T2N0
24 % Rec s/p
surgery
50 % T1N0
37 % T2N0
3 % T3N0/10 %
Postop
Mean 1.5 cm
51 % T1N0
37 % T2N0
12 % T3N0
HDR
PDR
LDR
LDR
Au198
Seeds
LDR
PDR
5 Gy (5.56 Gy) 9
fx
66 Gy (6670)
58 Gy (5062)
55 Gy
65 Gy (5577)
60 Gy (55>60)
45
NR
36
27
64
54
95 % LC
90 % RC
(95 %
with SS)
94 % LC
88 % RC
95 % LC
93 % RC
98 % LC
90 % LC
97 % RC
95 % LC
93 % RC
93 % CSS
NR
82 % DFS
88 %
94 % CSS
84 % DFS
59 %
86 % DFS
0%
3%
NR
2%
3%
2%
0%
0%
NR
0%
0%
2%
(continued)
Neck surgery and RT

for salvage only
Cosmetic and
functional outcome
inferior for large
tumors or with prior
surgery
Pulsed dose rate
15 % BT for postsurgical recurrence
20 % postop, 80 %
definitive BT (3
cases + EBRT)
Neck RT 11 %, neck
surgery 12 %
Good cosmetic and
functional outcomes
79 % previously
untreated, 21 %
recurrent
69 % macroscopic,
31 % microscopic
(postoperative)
BN case had
previously received
EBRT for tongue Ca
Similar outcome for
skin and vermillion/
mucosal lesions 79 %
SCC and 21 % Basal
Cell
Good cosmetic and
functional results
Good cosmetic and
functional results
no G3 or G4 toxicity

115
Primary
Buccal
Buccal
mixed
Buccal
n
234
45
42
Author
Nair 1988
India [172]
Shibuya 1993
[99]
Lapeyre 1995
France [70]
Table 5 (continued)
71 % T1-2 N0
29 % T3-4-X
7 % N+
Stage
19 % T1-3 N0
BT only
2%
EBRT + BT
35 Gy
79% EBRT
only
18 % T1N0
67 % T2N0
15 % T3N0
84 % EBRT
LDR
LDRseeds
66 Gy BT only
(67 %)
45 Gy EBRT +
34Gy BT
89 Gy BT only
2050 Gy
EBRT + 80 Gy BT
Dose rate Dose

LDR
65Gy BT only
Ra-226
50 Gy EBRT+
35 Gy BT
5060 Gy EBRT
only
51
Est.
48
Mo. f/u
36
81 % LC
57 %
LRC
87 % LC
LC, RC,
LRC 25
years
100 %
LC T1-2
48 %
74 % CSS
85 % OS
100 % T1
v 83 % T2
7%
22 %
Overall
survival 25
years
STN
42 % DFS
57 % N0
DFS
31 % N1
DFS
3%
20 %
BI
Au198 or Rn222
permanent seeds
with EBRT
21 buccal, 14 RMT,
10 BA
Neck mgmt. =
observation
Less BI for buccal vs.
RMT or BA 4
required surgery
Better LC with loop
tech; Successful SS
in 5/7 LR
Neck T1N0 observed
T2 or N+ either
surgery or RT
Successful SS in 3/9
RR
Dental shield used in
79 % cases
Comments
Single plane Radium
implants
Similar survival
Radium implants
and small field EBRT
116
D.J. Demanes
Buccal
7 Buccal
4 Lip 2
Nasal
748
13
Gerbaulet
2002 [2]
Ngan 2005
Hong Kong
[64]
85 % T1-2 N0
15 %T2-3 or
N+
14 % T1,
28 % T2
24 % T3, T4
34 %
27 % T1N0
73 % T2N0

Buccal
mixed
133
Tayier 2011
Japan [100]
LDR
LDR
LDRseeds
70 Gy BT only
(54 %)
50 Gy EBRT +
35 Gy BT
BT only
EBRT + BT
EBRT only
Surgery + EBRT
70 Gy BT only
(56 %)
28 Gy
EBT + 60 Gy BT
43
NR
71
75 % LC
(92 %
with SS)
81 % LC
65 % LC
45 % LC
78 % LC
75 % LC
(87 %
with SS)
89 %
64 %
41 %
26 %
66 %
7681 %
buccal
100 % lip
0%
NR
11 %
0%
NR
6%
Au198 permanent
seeds/variable EBRT
77 buccal, 18 RMT,
23 BA, 15 lip
No difference in
outcome EBRT
Only 1 patient
needed surgery for
BI
Book chapter
referenced above
Ra-226, Au-198,
Ir-192
More complications
with EBRT + BT
than BT only
4 patient also had
surgery for adverse
histology or positive
margins

117

a
33 HDR
61 % T1
33 % T2
5 % T3
1 % N+
Lip
Ghadjar
2012
Switzerland
[177]
55 % T1N0
36 % T2N0
9 % T4 or Tx
Lip
100
LDR
21 HDR
70 LDR
Ayerra 2010
Spain [176]
33 % T1N0
54 % T2N0
13 % T3N0
T1-T2N0
OT
OT
79 % T3N0
21 % T3N+
Stage
54 % T1N0
46 % T2N0
217
LDR-a
351
LDR-b
80 HDR
71 Surg
26 HDR
78 LDR
14 HDR
OT
OT
14 HDR
61 LDR
Site
OT
n
15 LDR
Yamazaki
2007 Japan
[175]
Umeda 2005
Japan [174]
Kakimoto
2003 Japan
[24]
Author
Inoue 2001
Japan [144]
None
None
2535 Gy
47 % EBRT
2540 Gy
34 % EBRT
3040 Gy
26 % EBRT
36 Gy
(2748)
95 % EBRT
None
30 Gy
(1360)
87 % EBRT
EBRT dose
(% cases)
None
37
4550 Gy
60 Gy (4866)
36 Gy (3229) 9 fx
32
48
156
57
61
98
21
6070 Gy
70 Gy (5593)
Ra-226
70 Gy (6185)
Ir-192
60 Gy (3260)
610 fx
None
68 Gy (50112)
boost
72 Gy (5994) BT
only
48 Gy (3260)
810 fx
60 Gy 10 fx BT only
61 Gy
Ra-226/C-137
59 Gy 910 fx
60 Gy 10 fx
BT dose
70 Gy (6575)
93 % LC
87 % RC
93 % LC
96 % RC
90 % LC
92 % RC
83 % LC
67 % RC
65 % LC
85 % RC
94 % LC
84 % RC
75 % LC
63 % RC
75 % LC
67 % RC
82 % LC
66 % RC
71 % LC
LC, RC,
Mo. LRC 25
f/u years
85
84 % LC
85 % RC
78
87 % LC
78 % RC
49
67 % LC
Table 6 High dose rate versus low dose rate brachytherapy lip and oral cavity no prior irradiation
77 %
77 %
90 %
98 %
CSS
46 %
57 %
CSS
84 % T1
72 % T2
73 % T1
52 % T2
95 % T1
94 % T2
86 %
CSS
81 %
CSS
89 %
CSS
Overall
survival
25 years
86 %
CSS
88 %
CSS
58 %
64 %
CSS
0%
0%
0%
0%
0%
0%
0%
0%
15 %
9%
7%
6%
8%
NR
NR
NR
0%
20 %
7%
BI
0%
8%
NR
NR
NR
21 %
5%
7%
STN
0%
33 % postop BT for positive surgical

margins
55 % acute G3 toxicity resolved
No outcome difference
Guide needles 90 % and plastic tubes

10 %
HDR equivalent to LDR
All implants local anesthesia

LC T1 85 %, T2 75 %, T3 65 %
Neck managed by observation with
prn salvage
EBRT doubled complication rate
(11 % vs. 26 %)
HDR had more T2 lesions

Elective neck dissection 4 cases only
SS successful in 69 % (28/41)
R-recurrence
Surgery preferable according to
author
Historical controls
Younger patients did better
Comment
Phase III (single plane lesions 1 cm
thick)
Successful SS in 4/5 Neck failures
118
D.J. Demanes
Stage
T1-3
65 % N+
84 % T1-2
16 % T3
? N+
T1-2 N0
T1-2 (nasal)
45 % EBRT + BT
N+
vs. 65 % EBRT
N+
T1-3
78 % prim/22 %
rec
51 % N+
67 % T1
33 % T2
50 % N2-3+
n
403
76
133
163
55
33
Author
Teo 1989
Hong Kong
[178]
Wang 1991
USA [179]
Chang 1996
Taiwan
[180]
Teo 2000
Hong Kong
[181]
Lee 2003
USA [182]
Lu 2004
Singapore
[183]
56 % LDR
IC
44 % HDR
IC
HDR IC
HDR IC
LDC IC
LDR-IC
Dose rate
LDR-IC
66 Gy
70 Gy bulky
disease
66 Gy (5072)
prim
3042 Gy rec
60 Gy
EBRT + BT
(32 %)
EBRT only
75 Gy (68 %)
(See
comment)
46.8 Gy + cone
down
64.868.4 Gy
6064 Gy
EBRT dose
6062.5 Gy
57 Gy
HDR
1054 Gy
LDR
10 Gy
(2 fx)
1824 Gy
516.5 Gy
(13 fx)
710 Gy
BT dose
1824 Gy
(3 fx)
29
36
prim
50 rec
80+
72
89 % LC
prim
64 % LC
rec
94 % LC
74 % LC
Grp I
94 % LC
Grp II
80 % LC
Grp III
95 % LC
BT versus
90 % LC
no BT
LC, RC,
LRC 25
Mo. f/u years
NR
Est. 85 %
LC T1-2
Est. 70 %
LC T3
NR
91 % LC
Table 7 Nasopharynxno prior irradiation and recurrent-persistent nasopharynx i.e., prior irradiation (bolded)
74 %
82 % DFS
86 %
91 %
77 % CSS
Grp I
96 % CSS
Grp II
82 % CSS
Grp III
90 % CSS
BT vs.
84 % CSS
no BT
NR
0%
0%
6%
1.9 %
4.2 %
13.8 %
NR
Overall
survival 25
years
STN
NR
NR
0%
2%
0%
3%
NR
BI
NR
(continued)
50 % chemo
no diff in disease control/
more toxicity
Compared to 70 Cases
EBRT (6570 Gy) only
LC = 60 %
Many with accelerated
hypofractionation, No
chemo
50 cases Grp I no BT
<72.5 Gy
71 cases Grp II + BT
72.575 Gy
58 cases Grp III + BT
>75 Gy
Comparison 346 EBRT only
to 163 with EBRT + BT
101 BT cases incomplete
responders and 62 BT as
adjuvant
1015 % chemo
EBRT + BT > EBRT only for
LC (> STN with
EBRT + BT)
33 % chemo
BI in 1 of the recurrent cases
Comments
Tables difficult to interpret

119
94 % % T1-2a
40 % N+
18 % T1N0
82 % T2N0
50 % T1-2 N+
145
175
280
274
Leung 2008
Hong Kong
[185]
Wu 2013
China [186]
Levendag
2013
Netherlands
[187]
Rosenblatt
2014 [188]
75 % Others
25 % T3-4 N2-3+
50 % T3-4 N0
Stage
87 % T1-2
37 % N+
n
38
Author
Ng 2005
USA [184]
Table 7 (continued)
HDR or
LDR IC
HDR or
LDR IC
HDR IC
HDR IC
Dose rate
HDR IC
51 % 70 Gy
EBRT only
49 % 70 Gy
EBRT + BT
70 Gy
(11 Gy
SBRT)
58 Gy
EBRT + BT
72 Gy EBRT
only
66 Gy EBRT
66 Gy
EBRT + BT
EBRT dose
60 Gy
HDR 9 Gy
(3 fx)
LDR
11 Gy
11 Gy
(34 fx)
20 Gy
1012 Gy
(2 fx)
BT dose
615 Gy
(25 fx)
29
NR
120
65
100 % LC
HDR
86 % LC
no HDR
90 % LC
HDR/
SBRT
85 % LC
no boost
61 % LC
no BT
54 % LC
BT (ns)
94 % vs.
85 % LC
96 % LC
EBRT + BT
88 % LC
EBRT only
LC, RC,
LRC 25
Mo. f/u years
47
96 % LC
63 % no
BT
63 % BT
NR
NR
72 % vs.
50 %S
91 % vs.
80 %
95 % vs.
83 % CSS
NR
NR
NR
2%
1%
Overall
survival 25
years
STN
93 %
0%
81 % DFS
0%
NR
NR
0%
0%
BI
0%
Randomized trial
chemoradiation BT boost
No difference even in
T1-2 N+ cases
Grade 34 toxicity not
significantly different
(22 % vs. 24 %)
Comments
82 % chemo
OS higher than DFS reflects
salvage or alive with disease
No chemo
Matched pair (n = 142)
EBRT 66 Gy alone vs.
EBRT + BT
Better outcome with
EBRT + BT than EBRT only
Compared with 173 EBRT
only (EBRT + BT better LC/
OS)
More chemo with EBRT
only vs. EBRT + BT (42 %
vs. 25 %)
Slightly more STN (NS) but
less neck fibrosis with BT
3 centers pooled boost data
for chemoradiation boost
T1-2 N0: HDR vs. no boost
(significant benefit to boost)
T3-4 N0: HDR or SBRT vs.
no boost (ns)
120
D.J. Demanes
23 % persist
77 % rec
Grp I 67 % T3-4
Grp II/III
80 % mod-adv.
84 % T1-2
(EBRT + BT)
31 % T1-2
(EBRT only)
57 % T1-2
43 % T3-4
62.5 % N+
T1-2
55 % N+
43
56
29
32
213
Choy 1993
Hong Kong
[189]
Syed 2000
USA [81]
Koutcher
2010 USA
[190]
Ren 2013
China [191]
Wan 2014
China [82]
171 HDR
IC
42 HDR
IS
HDR IC
LDR IC
(I-125)
LDR IS
(Ir-192)
LDR IS
Permanent
seeds
(Au198)
LDR IC

100 Rec NPC
38
Wang 1987
USA [35]
62 Gy (5070)
60 Gy
45 % 45 Gy
EBRT + BT
55 % 59.4Gy
EBRT only
Gp I
5060 Gy
Gp II/III
None
None
40 Gy
814 Gy
IC
13.6
18 Gy
(35 fx)
1220 Gy
(4 fx)
20Gy
49 Gy
60 Gy
20 Gy
53
39
45
84
39
NR
94 % LC
vs. 97 %
LC
97 % RC
vs. 95 %
RC
94 % LC
52 % LC
vs. 53 %
LC
93 % LC
Grp I
59 % LC
Grp II/III
80 % LC
persist
Est. 67 %
rec
NR
94 % vs.
97 %
87 % vs.
92 % DFS
97 %
78 % DFS
60 % vs.
57 %
41 % vs.
44 % DFS
74 % DFS
Grp I
47 % DFS
Grp II/III
Est. 50 %
Est. 70 %
DFS
38 % T1-2
15 % T3-4
NR
6%
NR
14 %
16 %
0%
NR
0%
NR
2%
0%
3%
IC Cs-137 EBRT (T3-4

EBRT only 66 Gy)
Study patients RT 60 Gy
Persistent = disease
identified <4 months after
RT
Trans-palatal exposure
(7 cases took 1 year to heal
wound)
Better LC if no base skull
involvement (81 % vs.
44 %)
27 % Grp I primary
61 % Grp II
recurrent-persistent
12 % Grp III new primary
(prior RT)
More complications in Grp
II/III
Recurrence treated EBRT
only or EBRT + BT
93 % chemo
Equal LC/OS
Complications 78 % EBRT
vs. 8 % EBRT + BT
Locally persistent (biopsy
proven) >1016 weeks
after IMRT
Locally persistent (biopsy
proven) after 10+ weeks
Chemoradiation doses
similar (30 % chemo)
Higher stage group for IS
No difference in RTOG
toxicity (G34 = 25 %)

121
Nasal
Vestibule
Ethmoid
Sinus
Nasal
Vestibule
Nasal
Vestibule
18
20
23
47
McCollough
1993 USA
[196]
Tawari 1999
Netherlands
[197]
Evensen
1994
Norway [84]
Langendijk
2004
Netherlands
[85]
Primary
Upper
Nasal &
Sinus
n
15
Author
Karim 1990
Netherlands
[195]
100 % T1-2 N0
87 % T1-2 N0
13 % T4N0
18 % T1-2 N0
82 % T3-4 N0
41 % T1-2
33 % T4
26 % recurrent
5 % N+
Stage
NR
most T2-4
MDR
HDR
LDR-IS
LDR-IC
LDR-IS
53 Gy
EBRT + MDR
50 Gy
EBRT + HDR
67.5 Gy
EBRT only
55 Gy
(5070)
5470 Gy
(6575) Gy
50 Gy
EBRT + BT
Dose rate EBRT dose

LDR-IC 64 Gy
Table 8 Nasal and paranasal sinuses (bolded) brachytherapy no prior irradiation
55 Gy (5060)
S + BT 59Gy
(4765) BT
only
30 Gy (2539)
EBRT + BT
16 Gy (840)
MDR
18Gy (3Gy/fx)
1228 Gy
Est. 25 Gy
BT dose
56100 Gy BT
only
62 Gy
EBRT + 20 Gy
BT
>24
>24
NR
>24
Mo.
f/u
NR
100 % LC
S + BT
92 % LC
BT only
86 % LC
EBRT + BT
79& LC
(95 % SS)
62 % LC
100 % LC
BT only
75 % LC
EBRT + BT
73 % LC
EBRT only
LC, RC,
LRC 25
years
70 % LC
all cases
(see
comment)
66 %
87 %
DFS
87 %
DFS
65 % OS
75 %
Est. 87 %
CSS
6%
17 %
NR
22 %
Overall
survival
25 years STN
68 %
12 %
DFS
0%
0%
NR
0%
BI
NR
N = 47 (32
EBRT + MDR, 9
EBRT, 15
EBRT + HDR
STN healed without
surgery, no cartilage
necrosis
8 patients developed
second primaries
N = 23 (4 S + BT, 12
BT only, 7
EBRT + BT)
2 STN = cartilage
necrosis
Comment
N = 45 (30 EBRT, 4
BT only, 11
EBRT + BT)
93 % postoperative
Most complications
eye related
N = 39 (12 EBRT,
9 BT only, 18
EBRT + BT)
100 % definitive RT
(26 % rec after
surgery)
STN healed without
surgery, no cartilage
necrosis
N = 50 postoperative
EBRT (+BT 40 %)
122
D.J. Demanes
Nasal
Vestibule
Nasal
Cavity and
Septum
Nasal and
Paranasal
64
35
Levendag
2006
Netherlands
[86]
Allen 2007
USA [198]
Teudt 2014
Germany
[88]
37 % T1-2 N0
63 % T3-4 or
N+
37 % recurrent
60 % T1-2
34 % T3-4
9 % N+
69 % T1N0
31 % T2N0
79 % T2-4
21 %
recurrent
N+ not
specified

a
Paranasal
Sinus
34
Nag 2004
USA [87]
HDR
LDR
HDR
HDRIORT
43 % BT only
57 %
EBRT + BT
50 Gy
(4063)
6570 Gy
EBRT only
None
4550 Gy
EBRT + BT
50
23 Gy (1035)
2.5 Gy/fx
65 Gy BT only
28
132
44 Gy (3 Gy/fx) NR
1520 Gy BT
only
1012.5 Gy
EBRT + BT
67 % LC
All Cases
91 % if
primary
86 % LC
92 % LC
(100 % SS)
68 % LC
72 %
83 %
CSS
82 %
86 %
CSS
58 %
62 %
50 %
DFS
14 %
4%
NR
0%
NR
1%
0%
0%
N = 34 (11 HDR
alone, 23
EBRT + HDR)
21 new primaries
received
EBRT + HDR
Gross residual
disease poor
prognosis
N = 64 (78 % BT only,
22 % incomplete S+
BT)
Study of
complications,
cosmesis, cost analysis
N = 68 (35 % EBRT,
12 % EBRT + BT, 53 %
EBRT + S)
BT vs. EBRT not
separately reported
Results no different
with RT alone vs.
S + RT
Failures continue after
5 years
Surgery with intraop
BT catheter insertion
N = 35 (54 % R0, 37 %
R1, 3 % R2)
32 % prior surgery and
12 % prior chemo
Detailed description of
complications

123
100 % Prim
rec
Various
48 % Prim
rec
52 % LN
only
Various
100 % LN
62 % Prim
rec
72 % T3-4
41 % N+
70 % Prim
rec
54 % N+
30 % LN
only
n
35
73
21
29
100
34
220
Author
Park 1991
USA [37]
Peiffert 1994
France [38]
Vikram 1985
USA [94]
Nag 1996
USA [199]
Zelefsky
1998 USA
[39]
Klein 1998
Germany
[200]
Puthawala
2001 USA
[40]
Treatment
sites
56 % Prim
rec
44 % LN
only
100 %
57 Gy
(3974)
59 %
Dose NR
76 %
54 Gy
(3080)
29 %
5075 Gy
100 %
Dose NR
100 %
Dose NR
Prior RT
None
LDR
Ir-192/I-125
LDR
None
Est.
50 %
58 Gy
(599)
16 %
Dose
NR
LDR
HDR
LDR
71 %
HDR
4550 Gy
None
None
Secondary
EBRT
Dose rate
60 Gy
LDR
(5070)
53 Gy
15Gy BT
only
7.5
12.5 Gy
EBRT + BT
171 Gy
I-125
40 Gy
Ir-192
1215 Gy
(17 fx)
48 Gy
Ir-192
75Gy I-125
60 Gy
BT dose
83 Gy
NR
Long
12-69
10
21
35
NR
Long
Mo. f/u
28
65 %
(CR + PR)
(Prim
cases
77 %)
51 % (5 yr
LRC)
67 % LC
All
89 % LC if
no prior
RT
25 %
(2 yr
LRC)
81 % LC
86 % LC
79 % LRC
LC, RC,
LRC 25
years
40 % LRC
Table 9 Salvage of primary site recurrences (excluding nasopharynx) and cervical lymph node recurrences (bolded)
20 %
33 %
DFS
38 %
20 %
72 %
30 %
65 %
CSS
55 %
DFS
13 %
0%
7%
NR
14 %
10 %
Overall
survival
25 years STN
20 %
NR
41 %
DFS
8%
3%
0%
NR
0%
0%
BI
3%
No surgery
Prior surgery 52 %
60 % hyperthermia, 40 %
chemo
BT neck surgery
84 I-125 (gross) and 33
Ir-192 (micro)
Prior neck surgery 55 %
No surgery
38 % inoperable
Difficult to quantify
EBRT
BT + surgery
Ir-192 (11 cases)
(4056 Gy)
I-125 (10 cases)
(6085 Gy)
Locally advanced or
recurrent disease
Comment
BT + surgery
Iodine-125 seeds (mean
13.4 mCi)
More complications with
flap reconstruction
No surgery
Ir-192 BT alone to 60 Gy
124
D.J. Demanes
100 % Prim
100 % LN
100 % LN
90
82
30
42
74
Glatzel 2002
Germany [42]
Grabenbauer
2001
Germany
[142]
Hepel 2005
USA [43]
Pellizzon
2005 Brazil
[201]
Nutting 2006
England [41]
76 % Prim
rec
16 %
perist/8 %
new
5 % LN
only
57 % Prim
rec
35 % Persist
Prim
8 % BT
only pall
Est. 62 %
OC
28 % OP
10 % Other
37
Ashamalla
2002 USA
[97]
100 %
50 Gy
83 %
52 Gy
(3065)
100 %
59 Gy
(2375)
Few
92 %
Dose NR
100 %
60 Gy
LDR seeds
None
38 %
Dose
NR
6%
Dose NR
LDR
HDR
HDR
72 %
LDR
5060 Gy
57 %
HDR
3070 Gy
None
60 Gy
24 Gy
(1224)
(314 fx)
34 Gy
(1848)
(34 Gy/fx)
55 Gy BT
only
29 Gy
(1462)
EBRT + BT
17.6 Gy
(12.923.9)
(37.5 Gy/
fx)
100 Gy
(80220)
1176
36
20
30
NR
NR
Long
37 %
LRC
57 %
LRC
67 % LC
57 % LC
63 % vs.
60 %
Stage III
vs. IIIIV
77 %
CR + PR
Rec 100 %
Persist
33 % LC
11 % LC
for
T > 2.5 cm
64 % LC
T < 2.5 cm
31 %
28 %
CSS
29 %
57 % vs.
15 %
Stage
III vs.
IIIIV
45 %
(2 yr
CSS)
37 %
(2 yr
OS)
53 %
1-25 mo.
DFS
Median
12 mo.
0%
0%
7%
9%
3%
0%
0%
0%
3%
9%
1%
0%
(continued)
BT + surgery
Negative surgical
margins better
3 severe ulcers and 1
neck fibrosis
BT + surgery 92 % of
cases
Fistula 9 %, Bleed 4 %,
Wound 8 %
36 % R2 surgery, 64 % No
surgery
43 % chemo, 36 %
hyperthermia
Primary site percentages

are estimates
Morbidity rates from
LDR Primary Table
No surgery
68 IS and 22 IC (NPC)
Persist cases did better
than recurrent cases
Au-198 seeds
BT palliation in 76 %

125
100 % LN
51 % Prim
rec
49 % New
prim
50 % N+
32 % Prim
rec
14 %
Paratracheal
54 % LN
only
74
103
156
Tselis 2011
Germany
[205]
MartinezMonge 2011
Spain [206]
Bartochowska
2012 Poland
[45]
13
34
54 % Prim
rec
46 % N+
15 % LN
only
100 % Prim
rec
50 % N+
22
Kupferman
2007 USA
[202]
Schiefke 2008
Germany
[203]
Perry 2010
USA [204]
100 % LN
n
30
Treatment
sites
66 % Prim
33 %
LN only
Author
Narayana
2007 USA
[44]
Table 9 (continued)
91 %
Dose NR
55 %
45 Gy
(4574)
100 %
60 Gy
(2272)
100 %
63 Gy
(2474)
100 %
65 Gy
(5072)
62 %
61 Gy
(6070)
Prior RT
77 %
Dose NR
None
55 %
45 Gy
12 %
40 Gy
(2070)
None
None
None
106 PDR
50 HDR
HDR
HDR
HDR
IORT
HDR
LDR
Secondary
EBRT
Dose rate
10 %
HDR
4050 Gy
PDR
2040 Gy
HDR
1230 Gy
(3-10 fx)
24 (1624)
40 Gy
(3240)
(410 fx)
30 Gy
(1236)
15 Gy
(1 fx)
30 Gy
(1544.8)
(1.5
3.5 Gy/fx)
60 Gy
(2060)
BT dose
2040 Gy
(510 fx)
52
14
23
25
30
Mo. f/u
12
38 %
(6mo)
LRC
86 % LC
78 % LRC
37 % LC
56 % LC
85 % LC
62 % LRC
67 %
LRC
LC, RC,
LRC 25
years
71 % LC
17 %
52 %
19 %
55 %
60 %
65 %
CSS
57 %
15 %
5%
5%
10
15 %
0%
a
Overall
survival
25 years STN
63 %
0%
1%
6%
0%
3%
15 %
5%
BI
3%
No surgery
5 % chemo, 10 %
hyperthermia
Intraoperative radiation
with multichannel open
tumor bed surface
applicator
Inoperable cervical
adenopathy
58 % prior surgery
(45 % with neck
dissection)
STN estimated
BT + surgery EBRT
49 % Stage IIIIV
63 % chemo
77 % BT+ surgery
62 % included neck
dissection
Comment
60 % BT + surgery, 30 %
BT only, 10 % BT + EBRT
6 % neck fibrosis, 3 %
persistent pain
BT + surgery (46 %
prior neck dissection)
126
D.J. Demanes
53 % Prim
rec
47 % LN
29 % Prim
rec
71 % LN
100 % Prim
rec
78 % Prim
rec
22 % New
Prim
25 % N+
76
57
19
51
Scala 2013
USA [208]
Teckie 2013
USA [93]
Zhu 2013
China [96]
Strnad 2014
Germany
[209]
100 %
64 Gy
(35145)
100 %
65 Gy
(6076)
98 %
66 Gy
(2474)
100 %
Dose NR
30 %
66 Gy
(5072)

56 % Prim
rec
44 % LN
30
Rudzianskas
2012
Lithuania
[207]
22 %
EBRT
46 Gy
(2867)
None
21 %
50 Gy
(3070)
24 %
45 Gy
(3069)
None
PDR
LDR seeds
I-125
HDR
IORT
HDR
IORT
HDR
60 Gy
27 Gy
if + EBRT
131 Gy
D90
15 Gy
(1020)
(1 fx)
12.517.5
(1 fx)
30 Gy
(12 fx)
58
11
NR
11
28
57 % LC
(5 yr)
CT 79 % v
no CT
39 %
68 % LC
57 % LC
62 % LC
67 % LC
26 %
60 %
DFS
18 %
43 %
37 %
DFS
47 %
53 %
DFS
18 %
0%
NR
0%
0%
12 %
0%
0%
0%
3%
No surgery
69 % chemo, 33 %
hyperthermia
Chemo (CT) > STN
43 % BT + surgery, 57 %
BT alone
70 % prior surgery
BT + surgery better
outcome than BT only
HAM applicator after
gross total resection
Negative surgical margins
better LC/DFS
BT + EBRT better
HAM applicator after
gross total resection
LC associate with
improved OS
Complications presented
in detail
Prior surgery and EBRT
Median LC 24 months

127
D.J. Demanes
128
often determined not only by cancer control but

also comorbidity. Functional outcomes are better
with brachytherapy alone than with the combination of brachytherapy and EBRT. Soft tissue
necrosis, varying severity and duration, occurs in
1520 % of cases, but it generally heals with conservative management. The occurrence of transient bone exposure is different from frank bone
necrosis, but the literature does not always make
the distinction. A reasonable estimate of BI is
about 10 % without a mandible shield and 5 %
with a shield. Relatively few patients require
major surgery for osteonecrosis. It is the authors
opinion that remedial measures should be instituted early for STN or bone exposure to prevent
progression to osteonecrosis. Brachytherapy
catheter spacing, technique, and dose significantly affect the morbidity rates.
More advanced oral cavity cancers (T3T4 or
N+) are usually treated with the combination of
brachytherapy and EBRT because larger lesion
can be difficult to implant and there is a greater
chance for regional spread. The type of lesion
(superficial spreading, exophytic, endophytic,
etc.) and the baseline condition of the mucosa
(i.e. leukoplakia) affect the LC rates and the
long-term prognosis (mucosal field defects).
According to the relatively sparse literature, the
LC rates for T3 and T4 (defined by involvement
of extrinsic tongue musculature) are 5070%.
The LC rate for T4 with bone involvement or
extension to adjacent structures is less than
50%. Surgery (with radiation therapy) is warranted for lesions that involve bone. In the
authors opinion, surgery probably increases LC
over radiation alone for these locally advanced
and deeply infiltrative lesions. Brachytherapy
can also be used for close or positive margins if
care is taken to minimize injury to flap wound
closures.
9.3
Oropharynx Low Dose Rate
Low dose rate (LDR) brachytherapy has been

successfully employed in the treatment of oropharyngeal cancer (base of tongue, tonsil, and
soft palate). Management strategy and outcomes
are dominated by lymphatic involvement and

the responsiveness of the disease to radiation
and chemotherapy. Brachytherapy is most commonly used in conjunction with EBRT. Most
patients are node-positive stage III or IV. When
brachytherapy is used, local control is achieved
in 8090 % of T1T3 cases. Control of T4
lesions again depends upon the definition of T4
(T4a LC 7580 % and T4b 5060 %). The functional outcomes (speech and swallowing) after
EBRT and brachytherapy are relatively good
compared to traditional surgery and postoperative radiation therapy. Chronic side effects of
dry mouth and decreased taste acuity continue
to be problematic occurrences after chemoradiation therapy. They are probably reduced when
brachytherapy is used, but documentation of
these somewhat subjective parameters is
difficult.
The precise role of brachytherapy for oropharynx cancer remains unsettled. Relatively
few physicians have the skill and training to perform these procedures, but that does not define
the usefulness of the modality. There are those
who believe EBRT alone is sufficient and those
who think brachytherapy should be a routine
part of radiation therapy of oropharynx cancer.
With the advent of intensity-modulated radiation
therapy and chemoradiation therapy, the questions have only deepened. Since implantation in
the oropharynx requires specific procedural
expertise, it may not be readily available for all
patients. There are no randomized trials or even
good historical comparisons to address questions about the comparative effectiveness of
chemoradiation therapy with and without
brachytherapy.
It has been discovered that the association of
HPV virus (P16 positivity) with squamous cell
carcinoma of the oropharynx significantly
improves the prognosis [16, 153156]. Standard
doses of chemoradiation therapy without brachytherapy commonly results in hospitalization for
acute toxicity and the adverse effects on pharyngeal muscular function and swallowing. In an
attempt to maintain efficacy but decrease morbidity, dose de-escalation trials for HPV-positive
patients have been performed or are currently
underway. Treatment of oropharynx cancer

should be stratified according to HPV status.
Initial results of studies using EBRT dose
(chemoradiation) to the primary tumor of 60 Gy
in HPV-positive patients have resulted in comparable outcomes to 70 Gy [17].
Morbidity reduction might also be accomplished by a combination of decreased EBRT
doses (5055 Gy) alone with use of TORS or
brachytherapy (Table 3 LDR) [31, 157, 158].
Advantages of TORS include avoiding morbidity
related to surgical access to the oropharynx and
there is usually no need for trachcostomy. The
advantage of brachytherapy is that deep margins
can be achieved with no tissue removal and there
is less radiation to the pharyngeal constrictors
and/or major blood vessels. In the authors opinion, this strategy should be applied regularly in
HPV-negative patients. Brachytherapy can also
be used in some HPV-positive patients, but the
incremental benefit may be less. Although specific indications have yet to be defined, brachytherapy should be used in patients with deeply
infiltrative disease or with gross residual or positive margins after TORS. The use of brachytherapy in soft palate cancer has the advantage of
preserving the structure and function, which, if
successful, eliminates the need for a palatal prosthesis. Chemoradiation is often sufficient to control the even bulky adenopathy in cancer of the
oropharynx. Neck dissection can be used for persistent disease, or the adenopathy can be
implanted in conjunction with the primary.
Brachytherapy of adenopathy is challenging due
to proximity to major blood vessels, but with
proper technique, it is safe and effective.
9.4
Oral Cavity with High Dose

Rate Brachytherapy
HDR has replaced LDR in many centers because

of its radiation safety advantages and the need for
close proximity to patients by medical personnel
for better care. HDR outcome reports began
appearing in the middle 1990s; therefore, the
HDR cohorts are fewer and smaller than the ones
for LDR. The patterns of care for early oral cav-
129
ity cancer, however, are similar. HDRbrachytherapy alone doses are 4460 Gy in 910
fractions, but the optimal dose is unknown. One
study showed no difference in outcome between
54 and 60 Gy [111]. The 6 Gy fraction size used
commonly in Japan is a response to the practical
concerns about how long to leave the implant in
the patient versus normal tissue tolerance benefits of smaller fractions. The GEC-ESTRO recommendations are for doses of 34.5 Gy per
fraction.
When brachytherapy is used as a boost with
external beam, smaller fraction sizes are more
feasible than when performing brachytherapy
alone. The administration of 2040 Gy EBRT,
in some Japanese studies for example, was probably a mechanism to reduce brachytherapy fraction size rather than an attempt to control
regional microscopic disease [140, 141, 145,
146, 160]. Implant volume, catheter spacing,
disease location (oral tongue versus floor of
mouth), and the use of mandible shields also
affect the outcomes. There are no systematic
studies to define the optimal number or size of
HDR fractions. Local control rates for early oral
cavity cancer are similar to LDR, namely, T1
8090 % and T2 7080 %.
9.5
Oropharynx High Dose Rate
HDR brachytherapy results for cancer of the oropharynx are presented in the tables. Chemotherapy
was used in some cases but not others because
most reports antedate the era of routine use of
chemoradiation. The EBRT course typically consists of 5060 Gy to the primary and lymphatics
followed by brachytherapy. Gross adenopathy is
treated either with EBRT alone (70 Gy), surgery plus EBRT (5060 Gy), or EBRT (50
60 Gy) with brachytherapy. These guidelines do
not take into consideration possible dose de-escalation based on HPV status. Local tumor control
rates for T1T2 are approximately 90 %, T3
80 %, and T4 variable. Cause-specific survival
rates are 6080 %. Morbidity rates and preservation of function are comparable to LDR
brachytherapy.
D.J. Demanes
130
9.6
Lip and Buccal Low Dose

Rate and High Dose Rate
Perioral cancer is subdivided into those of the

moist mucosal surface, the dry lip or vermillion
region, and the perioral skin, which is probably
similar to other skin cancers and only anatomically related to the mouth. Most lip cancers are
either basal or squamous cell carcinomas that
occur in sun-exposed area. They are more common in men than women and they occur more
commonly on the lower lip. The upper lip is more
subject to basal cell than the lower lip. The prognosis is worse for lesions greater than 3 cm,
poorly differentiated squamous cell cancer, those
that involve the upper lip or commissure, and
those with lymph node involvement. Treatment
becomes anatomically and functionally more
complicated if the lesion involves the commissure [173]. Lip cancer lends itself to early diagnosis, so most cases are T1T2 N0. Early lip
cancers have a low risk of spreading to lymph
nodes, a small chance of distant metastasis, and
excellent prognosis. Most lip brachytherapy is
interstitial and may be done with rigid needles or
soft plastic catheters. However, some custom
mold applicators have been designed to simplify
the treatment and reduce the dose to the mandible
[2, 54, 69].
All types of source loading and dose rates
(LDR, HDR, and PDR) appear to result in similarly good outcomes and excellent functional
results in perioral cancer. HDR lends itself to outpatient treatment. Local control and CSS rates for
T1T2 lesions are 95 % of cases. Surgical salvage is feasible and can be used to treat the recurrence at the primary or lymph nodes. External
radiation can be selectively used as definitive or
postoperative therapy to lymph nodes, or it can
be used in the form of an electron beam to treat
the primary. However, a course of electron beam
radiation is usually longer than a course of
brachytherapy. Brachytherapy can also be successfully employed for closing of positive surgical
margins.
Radiation-induced
acute
desquamation is common, but long-term functional outcomes are typically good. Soft tissue
and bone necrosis are unusual.
Buccal cancer is more aggressive than lip cancer, and it has a distinctly worse prognosis. It is
typically a well- to moderately differentiated
squamous cell carcinoma, and it has a higher propensity for lymph node metastasis especially
with locally advanced disease. It can be treated
with surgery alone, radiation alone, or with combined therapy. The optimal management strategy
is not clear, but brachytherapy alone is an acceptable option for early lesions whereas combined
therapy including EBRT and surgery or brachytherapy or both is more suitable for locally
advanced disease. A variety of brachytherapy
methods have been used including interstitial
tube and button afterloading and permanent
seeds. The largest reported experiences are with
LDR brachytherapy from France, India, and
Japan [100, 165, 172]. Local control for early
disease is approximately 80 % but is significantly
less for locally advanced disease. Survival correlates directly with local control and regional
spread. The published results are summarized in
Table 5.
Comparisons of HDR and LDR within the
same institution come mostly from Japan [144,
174, 175]. Cohort comparisons with historical
controls in T1T2 oral cavity cancers and one
small randomized prospective trial showed no
difference between HDR and LDR [144]. Another
small study of T3N0 cases revealed 67 % LC and
64 % CSS, which was not significantly different
between source loading methods [24]. Other
studies from Europe have drawn similar conclusions [176]. Due to the radiation safety advantages, it seems unlikely that randomized
comparison studies will ever be performed.
9.7
Nasopharynx Low Dose Rate

and High Dose Rate
The outcomes with radiation therapy of NPC are

dose dependent. Doses 70 Gy give better results
than doses of 66 Gy [192]. The addition of chemotherapy significantly improves local control
and survival, and chemoradiation is the standard
for NPC [193]. The role of brachytherapy
depends upon the extent of disease; however, the
use of intracavitary brachytherapy as initial treatment is most suitable for patients with primary
T1T2a lesions preferably with less bulky adenopathy. Lesions with disease invading the base
of skull or with intracranial extension are beyond
the range of brachytherapy applicators, and most
studies take these circumstances into consideration when reporting their outcomes. Technology
has migrated from LDR to HDR for practical reasons to allow outpatient treatment and to avoid
radiation exposure to medical personnel. Local
control is achieved in approximately 90 % of T1
T2 cases. Also, there have been significant
advancements in applicator design [119].
Improved local control as retrospectively compared to EBRT alone has been reported with the
HDR brachytherapy using the Rotterdam applicator in T1T2 disease. However, a randomized
controlled trial of locally or regionally advanced
disease, under the auspices of the International
Atomic Energy Commission (IAEC), failed to
demonstrate additional benefit with a low dose of
brachytherapy after 70 Gy of EBRT [188].
Criticism of the study included failure to perform
brachytherapy in approximately 20 % of the cases
randomized to the brachytherapy arm, and the
relatively low local tumor rate in T1T2 N2N3
cases. Chemoradiation with EBRT doses of
70 Gy and stereotactic boost have been shown to
be an effective alternative [187, 194].
Brachytherapy has also been used to treat
recurrent NPC where clinical circumstances are
usually complicated. Interstitial afterloading and
permanent seed methods have been used. The
results of IS implants have been reported to
achieve 57 % local control and 47 % disease-free
survival in presumably selected recurrent disease
and new primaries in previously irradiated
patients [81]. Effective palliation can be achieved
with permanent seeds, but such treatment is
unlikely to be curative [94, 97].
The results of brachytherapy for lesions of the
nasal vestibule have been favorable for T1 and T2
lesions. A 92 % 5-year local control was achieved
in 64 patients with T1T2 N0 tumors using 44 Gy
HDR brachytherapy [86]. T3 patients were
treated with surgery and postoperative radiation
therapy, while local failures were surgically sal-
131
vaged. There were no lymph node recurrences in

untreated necks. Others have achieved similarly
good results using similar brachytherapy techniques and policies [84]. EBRT alone has also
been used effectively [196]. The relative efficacy
of surgery, brachytherapy alone, EBRT alone, or
in various combinations has not been directly
compared for this cancer. This disease, when
treated early, is effectively controlled with
brachytherapy alone.
9.8
Salvage Brachytherapy Low

Dose Rate and High Dose Rate
Recurrent and persistent cancers of the head and

neck are serious illnesses with a high potential
for morbidity. Recurrence may involve the primary site only, the neck only, or both. Persistent
disease is typically defined as residual disease
within some defined period after completion of
therapy (usually less than 3 months). New primary cancers involving the head and neck also
occur in approximately 20 % of patients cured
of their original disease [210213]. Salvage
therapy then encompasses a heterogeneous
group of patients who may have been treated
with surgery, radiation, and chemotherapy in
various combinations. The extent of the disease
at presentation, the disease-free interval, prior
treatment, and comorbidities all impact treatment selection, prognosis, and complication
rates. Treatment intent may be curative or
palliative.
Two basic requirements for previously irradiated patients to receive surgery include a through
consultation with an appropriately skilled physician and a robust support system within the operating facility. Brachytherapy should be viewed as
a valid alternative to surgery that entails an
attempt to preserve the structure and function of
the involved structures. There are no studies that
directly compare outcomes of brachytherapy
with surgery in recurrent cancer of the head and
neck, and the complexity and variety of circumstances make a direct comparison difficult. Bone
involvement would strongly increase the indications for surgery. Re-irradiation may consist of
D.J. Demanes
132
brachytherapy, external beam, or a combination

with or without chemotherapy.
In patients who have had surgery alone,
brachytherapy and EBRT are often used as salvage whereas brachytherapy alone may be more
suitable for previously irradiated patients.
Brachytherapy with or without EBRT can be
combined with re-resection. The extent of the
disease should be carefully assessed by physical
examination and imaging studies before proceeding with salvage brachytherapy. Biopsy confirmation is a prerequisite.
Tumor control and morbidity rates with
brachytherapy salvage depend upon case selection and clinical circumstances. Local control
rates up to 7580 % have been reported, but more
realistic percentages are 5060 %. Survival rates
after salvage brachytherapy ranges from about 20
to 50 %. The author believes that soft tissue and
bone necrosis risks are greater with salvage treatment than with primary therapy, but the numbers
in the literature appear to be similar to primary
treatment.
Isolated neck recurrence in patients with early
cancer of the oral cavity whose necks were managed expectantly can often be effectively managed by surgery, with or without postoperative
radiation therapy. Neck irradiation alone is used
for patients with diffuse nodal involvement or
unresectable disease. In previously irradiated
patients, the use of brachytherapy with neck dissection is a useful strategy to reduce morbidity.
Disease control in the previously irradiated neck
largely depends upon whether the disease is
resectable or not. Ideally, all gross disease should
be removed, and brachytherapy can be used for
residual microscopic disease. Brachytherapy
without surgery may be used in patients with
unresectable disease, but these neck implants
require the skill and knowledge to perform
implants in and around major vasculature. Image
guidance is helpful. Disease that invades or fully
encircles the carotid, prior neck dissection, and
lesions invading the skin carry considerably more
risk or acute and chronic complications. Patients,
families, and other physicians should be counseled accordingly. Disease control rates in the
neck range from 25 to 70 % among cases selected
for treatment. Simultaneous recurrence at the primary site confers a poorer prognosis.
10
Complications
and Management
Complications may be divided into those associated with the brachytherapy procedure and those
associated with the radiation. The measures for
avoidance of procedural complications (bleeding, infection, airway issues, venous thrombosis,
decubiti, etc.) have in large part been described
earlier in the chapter. In general, procedure
related complications are unusual. Oral rinses,
nutritional support, frequent suctioning, catheter
cleaning, and proper airway management are
important measures for avoiding procedural
complications. Acute radiation reactions do not
emerge until several days after the brachytherapy.
The patient and the family need to be informed
about the course of the radiation effects and optimal home care measures. Home care recommendations include:
1. Oral rinses with 12 % bicarbonate every
12 h while awake.
2. Keep implant exit sites clean and dry; avoid
lotions and salves.
3. Washing and showering face and neck starting 24 h after implant removal.
4. Oral intake advance as tolerated for
patients who can swallow.
5. Dietary supplementation and feeding tube
support as needed.
6. Tracheostomy site keep clean and dry;
dress daily or more often if needed.
7. Prophylaxis for trismus preferably with
specifically designed commercial devices.
8. Make arrangements for speech and swallow
evaluation.
9. Make arrangements for follow-up dental
care.
10. Call brachytherapy physician for questions
or acute concerns.
11. Emergency room referral for urgent concerns (breathing, bleeding, acute infections,
etc.).
12. Scheduled follow-up with all relevant

physicians (primary care, head and neck,
medical, and radiation oncologists).
Chronic complications of head and neck
brachytherapy such as soft tissue necrosis (STN)
and bone injury (BI) have already been discussed
in the context of each disease site. Microvascular
injury is thought to be underlying mechanism
[214]. More recently, the complex pathophysiology has been described [215]. The predisposing
factors and standard treatment have also been
summarized [150, 215]. The rates of STN and BI
are presented in the tables included. However, the
extent and consequences of these occurrences are
not apparent from the figures. Importantly, the
rate of BI requiring surgery is relatively low, and
it can be significantly reduced by proper implant
techniques and the use of mandibular protection
devices. There may be a greater incidence of soft
tissue necrosis with brachytherapy than with
EBRT, but it usually heals without permanent
effects. Cranial neuropathy, although uncommon, may also be somewhat more common with
brachytherapy than with EBRT. The nerves at
most risk are the hypoglossal for tongue implants
and the vagus, glossopharyngeal nerves, and
sympathetic chain for neck implants.
The use of medical measures such as pentoxifylline 400 mg and vitamin E 400 mg three times
daily has been shown to significantly improve the
rate of healing in cases of soft tissue and bone
injury [216]. The author recommends early
administration of these medications for any
apparent soft tissue injury because the rate of side
effects from the medication is low.
Hyperbaric oxygen (HBO) therapy may also
aid in the healing of soft tissue and bone injury
[51, 52, 217, 218]. A multicenter French randomized trial of HBO, however, stopped enrollment
at only 68 cases because of concerns about worse
outcomes in the HBO arm [219]. The study concluded there was no benefit of HBO for osteonecrosis of the mandible. The author does not
believe that one such study is definitive and wonders if perhaps medications and HBO may have
an additive benefit in patients with osteonecrosis.
Another setting for the use of HBO is in a preven-
133
tive protocol for patients who have scheduled

dental procedures. HBO treatments are recommended before and after the invasive procedures
[220]. Regardless of the debate about treatment
efficacy, measures to prevent necrosis are preferable. Cessation of smoking is another key factor
in avoidance of complications.
Brachytherapy as the sole modality for lip and
oral cavity cancer simultaneously enhances disease control and reduces morbidity. Relatively
more radiation is given to the target, and less
radiation is delivered to adjacent normal structures which thus limits the side effects of radiation on saliva production and taste acuity.
Brachytherapy similarly improves the dosimetry
index (relative tumor to normal tissue dose) when
it is used to supplement EBRT. Dose reduction to
adjacent mucosa, salivary tissue, taste buds, the
pharyngeal constrictors, and muscles of mastication reduces acute and late morbidity, particularly
when chemotherapy is administered with
EBRT. A review of the late complications gives
an account of the expected complication rates for
radiation therapy of head and neck cancer [221].
One important example is accelerated carotid
artery atherosclerosis [222, 223]. The dosedependent rate and the severity of vascular injury
could be reduced by the employment of brachytherapy. Similarly, reduction of dose and injury to
pharyngeal constrictors could improve long-term
swallowing function. Despite these and other
potential morbidity reduction advantages, there
are no outcome comparisons between chemoradiation alone and chemoradiation with
brachytherapy.
Secondary aerodigestive malignancies occur
in a relatively large percentage (20 %) of
patients with head and neck cancers. Lung,
esophagus, and head and neck sites must be
monitored second primary cancers [211]. The
patients must be followed carefully for life,
screened, and evaluated for recurrence of the
original primary, which tends to occur earlier,
and a second new primary cancers, which tend to
occur later than recurrences. The distinction may
be difficult in patients with adjacent recurrences,
similar histology, and moderately long diseasefree intervals. While hypopharynx has the high-
D.J. Demanes
134
est rate for second malignancy, larynx has the

lowest rate. However, both sites have the propensity to be associated with bronchogenic carcinoma. On the other hand, the most common site
for the second primary cancers for oral cavity
and oropharynx primaries is a new head and
neck cancer. The complication rates are markedly higher for patients who continue smoking
and conversely are significantly lower in patients
who stop smoking. Measures to help the patient
avoid smoking, drinking, and HPV exposure are
general health improvements that favorably
impact on outcome.
11
Conclusions and Future

Developments
Brachytherapy is an integral part of the treatment

of head and neck cancer. It may be used alone or
in combination with EBRT. T1N0 and small
T2N0 lesions of the lip, nasal vestibule, buccal,
and oral cavity are often successfully treated
with brachytherapy alone. LDR equivalent doses
of 6570 Gy and dose rates of 0.30.6 Gy/h are
recommended. Mandible spacers and shields are
used to improve dosimetry. T3T4 lip and oral
cavity lesions are more difficult to control; however, brachytherapy can be used as a boost to
EBRT, or it can be administered after surgery for
lesions with close or positive margins, with or
without EBRT depending upon the status of
lymph nodes. Brachytherapy is also used as a
boost to EBRT for oropharynx cancer. Combined
doses are 5060 Gy of EBRT and 2530 Gy
LDR equivalent brachytherapy. Such treatment
is as effective as radical surgery and postoperative radiation therapy, but preservation of structure and function results in improved quality of
life. Transoral robotic surgery is a new surgical
paradigm, which has similar advantages for
selected patients. The discovery of HPVassociated head and neck cancer has altered the
management and prognosis for these patients.
Finally, intracavitary brachytherapy in T1T2
nasopharynx cancer has shown to improve local
control. The routine use of chemoradiation, however, has probably reduced the impact. A recent
randomized trial did not demonstrate a difference from chemoradiation without brachytherapy, but the study can be criticized for
randomization deficiencies and poor local control compared to previous reports. Brachytherapy
has been used extensively as the salvage treatment for previously irradiated patients. The recommended dose is in the range of 5060 Gy
LDR equivalent.
HDR, LDR, and PDR source loading appear
to be equally effective, but there are few direct
comparisons. The advantage of HDR and PDR
relates to radiation safety. HDR involves once- or
twice-daily treatment, so it is the most convenient
in terms of nursing and patient management. The
recommended doses of HDR are still being determined. HDR fraction sizes are preferably in the
34.5 Gy range, but it is not always practical. The
author often uses HDR 3.54.0 Gy 56 fractions (i.e., 17.524 Gy) when combined with
EBRT. Additionally, HDR monotherapy
(56 Gy 910 fractions) has been used in Asia
(the author prefers 44.5 Gy 1012 fractions);
lower can be used for patients with postoperative
margins and perhaps for safety reason, in the
treatment of patients with prior radiation. There
is no consensus or uniformly accepted standard
of HDR dose and fractionation for most head and
neck cancers. Brachytherapy can also be done
with surgery to improve outcomes and to reduce
radiation morbidity. Intraoperative brachytherapy
consists of the placement of brachytherapy catheters or devices during surgery followed either by
immediate single fraction source loading (if there
is a shielded operating room or low-energy
source) or by fractionated dose delivery after
wound healing and 3D dosimetry calculation.
The potential of intraoperative brachytherapy has
yet to be fully explored.
An experienced team of physicians, physicists, nurses, and therapists are needed to perform
head and neck brachytherapy. Coordination with
hospital personnel, operating room and ward
staff members, and other treating physicians is a
key factor in establishing a successful service.
Strong radiation safety practices, quality assurance, and standard operating procedures are
needed for the program to succeed. Physicians
and other persons must have proper training and

experience to perform these complicated
procedures.
Technically improved and more consistent
implants can be achieved with image guidance.
Ultrasound, in its current form, has limited
value, and CT scan simulation is usually performed after the implant procedure is completed. However, it would be better if there was
image guidance of catheter placement during
the procedure, and the simulation radiography is
obtained at the end of the procedure so improvement in the implants could be made while the
patient is still under anesthesia. A new generation of portable CT scanners is being developed
which will serve this purpose. Although CT
scanning does not permit true real-time needle
guidance, there is clear potential for improvement in both implant quality and efficiency of
the brachytherapy with this imaging modality.
MRI scanning is another image guidance option,
but the needle images are not as distinct and
catheter relationships are more difficult to
appreciate. MRI-ready operating rooms are also
not readily available.
Another guidance approach with excellent
potential is the use of navigation technology. In
this system, fiducial tracking devices are affixed
to the patients head and to the implant needles.
Optical and electoral magnetic navigation tools
can then be used to guide the insertion of the
implant needles. A 3D image (CT, PET/CT or
MRI) can be fused with the navigation technology, so the tumor target and normal tissue anatomy was virtually displayed during the
procedure. Such relationships can be coordinated
with a preoperative CT, PET-CT, or MRI datasets
and fused for optimal display of the disease and
relevant anatomy. This system is similar to those
used in neurosurgery and orthopedics. The challenge for brachytherapy is that soft tissue and
vascular structures may be deformed and displaced during the implant. The use of intraoperative CT with navigation allows iterative
accounting of changing anatomy and catheter
relationships. This image guidance will surely
improve the quality, efficiency, and effectiveness
of brachytherapy.
135
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Oncol 4:265273
Breast Brachytherapy: Interstitial

Breast Brachytherapy
Csaba Polgr and Tibor Major
Abstract
Interstitial brachytherapy used in the management of breast cancer has

enjoyed broad acceptance among many in the field. It is a complex
technical procedure that requires great skill and significant experience to
be properly performed. We present a detailed and thorough discussion of
the technique, evidence, and results in this chapter.
Introduction
Before the era of breast-conserving therapy,

interstitial brachytherapy (BT) implants (with or
without external-beam irradiation) were used to
treat large, inoperable tumors [1, 2]. Later
interstitial BT with rigid needles or multiple
flexible catheters was used to deliver an additional
(boost) dose to the tumor bed after breastconserving surgery (BCS) and whole-breast
irradiation (WBI) [36]. In the last two decades,
the new concept of accelerated partial-breast
irradiation (APBI) opened a new perspective for
breast BT [79]. APBI is an attractive treatment
C. Polgr, MD, PhD, MSc (*)

Center of Radiotherapy, National Institute of
Oncology, Budapest, Hungary
T. Major, PhD
Department of Medical Physics, Center of
Radiotherapy, National Institute of Oncology,
Budapest, Hungary
approach that shortens the 57-week course of

conventional postoperative radiotherapy (RT) to
45 days. The acceleration of RT eliminates
some of the disadvantages of the extended treatment period, especially for elderly patients,
working women, and those who live at a significant distance from the RT facility. The rationale
for APBI is that the majority of local recurrences
(LRs) occur in close proximity to the tumor bed
[3, 7, 9]. Less than 20 % of LRs appear elsewhere in the breast, and the absolute number of
such failures is very low (e.g., far less than 1 %
per year and similar to the rate of new contralateral tumors) [10, 11]. In addition, some elsewhere
failures are likely to be new primary breast cancers that arose after initial therapy and hence
would not have been prevented by WBI. Thus, in
the last two decades, APBI using low-dose-rate
(LDR), high-dose-rate (HDR), or pulsed-dose-rate
(PDR) interstitial implants has been intensively
evaluated in phase III (and later in phase III)
studies as a possible alternative to conventional
WBI [79].

DOI 10.1007/978-3-319-26791-3_8
145
C. Polgr and T. Major
146
The first technique utilized in early APBI

studies was multicatheter interstitial BT [1218].
The implementation of all other techniques
(including 3-D conformal external-beam
irradiation and intraoperative radiotherapy) to
deliver APBI was based on the success of these
phase III clinical studies using multicatheter
breast implants. Beyond classical interstitial BT,
recently new intracavitary balloon applicators
have been developed to decrease the existing
barrier against the widespread use of multicatheter
BT [19, 20]. Furthermore, permanent breast seed
implants have been also implemented as an
alternative for stepping-source multicatheter BT
[21]. However in this chapter, we will give an
overview on interstitial breast BT used as a boost
or sole postoperative irradiation after
BCS. Management of ipsilateral breast tumor
recurrence (IBTR) as well as breast intracavitary
and seed techniques will be reported in other
chapters of this text.
Indications for Interstitial

2.1
Indications for Tumor

Bed Boost
irradiation [3, 6, 8]. Other factors (e.g., lymphovascular invasion (LVI), high-grade tumors, and
large tumor size >3 cm) can be also considered
for the indication of a tumor bed boost.
Traditionally LDR BT, electrons, or photons
have been used to deliver the boost dose to the
tumor bed [1, 22, 2529]. Later HDR BT has
been also accepted as a safe alternative boost
modality [5, 3039]. However, a controversy still
exists regarding the optimal boost technique.
Interstitial BT is preferable in some anatomical
situations, especially in cases of deep-seated
tumor beds in large-volume breasts. Obviously,
BT offers the practical advantage of more
conformal treatment of small volumes to higher
doses and lower doses to the skin [6, 40]. Van
Limbergen [6] compared dose distributions of
4.515 MeV electron boosts to different settings
of interstitial implants. He found that for target
depths reaching beyond 2.8 cm under the skin,
interstitial implants had a ballistic advantage
delivering significantly lower skin doses than
electron beams. Thus, in addition to externalbeam boost modalities, interstitial BT is a
standard treatment option to deliver an additional
dose to the tumor bed after BCS and WBI.
2.2
The standard technique of RT after BCS is to
treat the whole breast by teletherapy via tangential
fields up to a total dose of 4550 Gy. The main
rationale to give an additional dose of 1025 Gy
to the tumor bed after WBI was based on the
clinical observation that 67100 % of ipsilateral
breast recurrences originated from the vicinity of
the original index lesion [3]. Based on the
analysis of dose-response curves, Van Limbergen
et al. [6] reported that above 50 Gy, an increase of
15 Gy would reduce the LR rate by a factor of 2.
To date, multiple randomized trials have
confirmed that a boost dose of 1016 Gy after
50 Gy WBI significantly decreased the LR rate
(Table 1) [3, 2225]. Patient age less than 50
years; close, microscopically positive, or
unknown surgical margins; and the presence of
an extensive intraductal component (EIC) are
generally accepted as indications for boost
Indications for APBI
Patient selection in early APBI clinical trials

was flawed or absolutely inadequate [1215,
4143]. In later studies patient selection criteria were refined excluding patients with high
risk for multicentricity from APBI protocols
[17, 18, 4553] Based on the limited scientific
evidence obtained mainly from phase III prospective clinical trials, professional scientific
organizations both in the USA and Europe
have generated and published their recommendations on patient selection for APBI Table 2
[4, 5457]. These recommendations provide
conservative and useful clinical guidance
regarding the safe use of APBI outside the context of a clinical trial. In addition to the ASTRO
suitable and GEC-ESTRO good candidate
groups, both the ASTRO consensus guidelines
and the GEC-ESTRO recommendations
Breast Brachytherapy: Interstitial Breast Brachytherapy
147
Table 1 Results of randomized boost versus no boost trials
Clinical trial
EORTC [22]
Patient no. Technique

5318
EBI/LDR BT
5-year LR
Boost dose Median FUP boost vs. no
(Gy)
(years)
boost (%)
1516
17.2
4.3 vs. 7.3
Budapest [3, 23, 24]
627
ELE/HDR BT
1216
Lyon [25]
1024
ELE
10
3.3
6.3 vs.
13.3
3.6 vs. 4.5
20-year LR
boost vs. no
boost (%) p-value
12.0 vs.
<0.0001
16.4
NR
0.0017
NR
0.044
EORTC European Organisation for Research and Treatment of Cancer, FUP follow-up period, LR local recurrence, EBI
external-beam irradiation (photons or electrons), ELE electrons, LDR low dose rate, HDR high dose rate, BT
brachytherapy
Table 2 ASTRO, GEC-ESTRO, ABS, and DEGRO patient selection criteria for the routine use of APBI outside of
clinical trials
Characteristic
Patient age (years)
Tumor size (cm)
Surgical margins (cm)
Nodal status
Histology
ASTRO [56]
60
2
0.2
pN0 (SNB or AD)
IDC or other
favorable subtypes
ABS [56]
50
3
Negative
pN0 (SNB or AD)
All invasive
subtypes + DCIS
DEGRO [54]
>70
<2
Negative
pN0 (SNB or AD)
IDC luminal A
type
Allowed
Allowed
NS
NS
Not allowed
Not allowed
NS
NS
EIC
LVI
Receptor status
Not allowed
Not allowed
Unicentric only
Clinically unifocal
with total size 2 cm
Not allowed
Not allowed
ER positive
GEC-ESTRO [4]
>50
3
0.2
pN0 (SNB or AD)
IDC, mucinous,
tubular, medullary,
and colloid cc.
Not allowed
Not allowed
Unicentric only
Unifocal only
ILC
DCIS
Multicentricity
Multifocality
Not allowed
Not allowed
Any
NS
Not allowed
Any
HG
Neoadjuvant therapy
Any
Not allowed
Any
Not allowed
NS
NS
Not allowed
NS
ER and PR pos.,
HER2 neg.
12
NS
ASTRO American Society for Radiation Oncology, GEC-ESTRO Groupe Europen de Curiethrapie-European Society
for Therapeutic Radiology and Oncology, ABS American Brachytherapy Society, DEGRO Deutsche Gesellschaft fr
Radiotherapie, SNB sentinel node biopsy, AD axillary dissection, IDC invasive ductal carcinoma, ILC invasive lobular
carcinoma, DCIS ductal carcinoma in situ, LVI lympho-vascular invasion, EIC extensive intraductal carcinoma,
ER estrogen receptor, PR progesterone receptor, HG histologic grade, NS no statement
defined an intermediate group of patients (the

so-called ASTRO cautionary and GECESTRO possible candidate groups) for
whom APBI considered acceptable only with
caution or preferably in the context of prospective clinical trials [4, 56]. The third group of
women (defined as the ASTRO unsuitable
and GEC-ESTRO high-risk groups) should
not be treated with APBI, as there is enough
evidence against the use of APBI for such
patients. The validity of these recommendations has been tested in several studies and
highlighted the limitations of such guidelines
[52, 57, 58]. However, until large-scale randomized clinical trial outcome data become
available, these guidelines serve as clinically
useful tools for the selection of patients for
APBI and promote further clinical research
focusing on controversial issues in the radiation therapy of early-stage breast carcinoma.
148
2.3
Techniques
Technically there is no difference between

whether the treatment is a boost or sole postoperative irradiation after (BCS). Different techniques exist, but the implantation is always
performed using stainless steel needles with
sharply beveled tips (trocars) which are then
exchanged with flexible plastic catheters. Then,
the catheters are fixed to skin with locking buttons without skin sutures and are trimmed at a
consistent length. Using the comfort catheter
system (Elekta AB, Stockholm, Sweden), which
is a catheter-within-a-catheter system, there is
no catheter protruding past the fixation buttons
and therefore it is very comfortable for the
patient. Just for the irradiation, another thin
inner catheter is temporarily inserted into the
outer one (Fig. 1) in which the 192Ir source can
be advanced after connecting it to the
afterloader.
There are centers where the boost dose is
delivered only with one or two to three fractions.
In this case the rigid needles are used not only for
insertion but also for the irradiation. The needles
are inserted under ultrasound (US) guidance by
freehand technique or using a template [59].
Fig. 1 The Comfort

catheter system with
the implanted outer
catheters and one inner
catheter. The outer
catheters are fixed to
skin with locking
buttons
Whatever dose delivery method is used, the

most important goal during implantation is to
place the catheters in an appropriate distribution
in order to geometrically cover the target volume.
In the intraoperative setting only, visual inspection of the lumpectomy cavity helps to place the
needles, but when the implantation is performed
a few weeks after cavity closure, image guidance
is always needed for proper implantation.
Different types of imaging modalities can be
used, including US, mammography, and CT.
2.4
Freehand Catheter Insertion
Historically, this was the first breast BT technique. The catheters are inserted into the breast in
the operating room while the skin incision is
open. The edges of the lumpectomy cavity are
marked on the skin, and under visual inspection,
needles are inserted manually with appropriate
geometry in order to cover the target volume and
ensure homogeneous dose distribution. When all
catheters are in place, the surgeon closes the
wound cavity. A few days later, postimplant CT
scans are taken for treatment planning. This
technique requires thorough skill and experience
from the radiation oncologist. Moreover, without
149
imaging, it is difficult to determine the target

volume related to the catheters. For these reasons
this technique is less commonly used.
When the BT treatment is performed
postoperatively with closed cavity in a separate
procedure, all needles can be inserted under US
guidance, provided that the excision cavity is
readily seen. First, the cavity is projected and
marked on the skin and then each needle, one by
one, is inserted using real-time US guidance [60].
This technique is also very skill dependent, since
holding the US probe and inserting a needle at
the same time is quite challenging and requires
extensive knowledge and much experience.
localization, contrast medium is injected into

lumpectomy cavity by US guidance for better
visualization. Having taken a mammographic
image, the cavity and the holes of the templates
are clearly seen on the superimposed image,
and the template coordinates of the needles covering the target volume can be easily identified.
Since the breast hangs by gravity, the template
can be pushed up against the chest wall, and in
this way adequate deep-plane position can be
achieved. Finally, when all needles are in place,
they are replaced with plastic catheters, and the
treatment planning is done the next day. The CT
image acquisition and the dose delivery are done
in the supine position.
2.5
Image-Guided Catheter
Implantation
When performing implantation a few weeks after

the lumpectomy, some kind of imaging before or
during the insertions is necessary for placing the
adequate number of catheters in the correct
geometry in relation to the cavity volume. The
use of a template around the involved breast is of
great help to achieve this. However, the template
with the holes has to be visualized on an image
together with the cavity geometry in order to
select the appropriate holes to be used for needle
insertions.
2.6
Implantation
with Mammography
Generally, but not exclusively, the implantation

of catheters in breast BT is performed in the
supine position which is the standard patient
positioning in RT. However, the implantation can
be done in the prone position as well. An advantage of this technique is that the breast tissue
pulls away from the chest wall, pectoral muscles,
and ribs which makes the deep-plane implantation easier. The patient is lying on a stereotactic
core needle breast biopsy table, and with a template and built-in mammography equipment, the
catheters can be placed accurately in relation to
the target volume [61]. To help the cavity
2.7
Implantation with US
Guidance
Ultrasound imaging is an effective method to

localize the surgical cavity, define the target
volume, and guide the implantation [61, 62]. As a
first step, the dimensions of the cavity are defined
as the largest extension of the hypoechoic region
in the three cardinal directions. The distance
between the superior cavity wall and skin and the
depth of chest wall can be also measured. After
target volume localization, the implant geometry
is designed and the entry and exit points of the
needles are marked on the skin. Then, under realtime US guidance, the superficial needles are
inserted one by one. For intermediate- and deepplane needles, a template can be used which
makes the insertions of the remaining needles
easier.
2.8
Implantation with CT
Guidance
Various CT-based techniques exist for interstitial brachytherapy, but the entrance and exit
planes or points of the catheters on the skin are
always determined using the 3-D rendering of
the target volume and patient anatomy. When
the implantation and the imaging are done
in the same room after placement of a few
150
needles (e.g., in the deep plane), a CT image

can be used for initial evaluation of target coverage. Then, the remaining needles are inserted
manually in a standard pattern with 1.01.5-cm
separation [63]. If needed, additional CT imaging can be performed, and with frequent imaging, the optimal catheter placement is ensured.
Planning the catheter positions on the skin can
be done with radiopaque angiographic catheters placed on the involved breast [64] or using
a plastic template during preimplant CT imaging [7, 65]. Then, using 3-D rendering of
patient anatomy and virtual simulation, the
appropriate catheter positions can be defined.
A few needles (e.g., deep plane) can be inserted
freehand with or without real-time intraoperative US guidance. The remainder should be
guided by a template. Alternately, all needle
insertions are performed via template. When
the imaging and insertion are performed in one
session, a CT-compatible template is placed on
the involved breast after the radiation oncologist locates the scar and palpates the seroma.
For template fixation, catheters or needles can
be used in a few template holes, and these can
also help orient the template in a 3-D view
[61]. Contrast material can then be injected
directly into lumpectomy cavity to help in contouring the cavity. With 3-D rendering and creating a needles eye view, visualization of the
proposed needle holes can be identified. In
another technique, two CT image series (pre
and post implant) are used for implantation and
planning [7, 65]. First, one day before the
implantation, a CT-compatible plastic template
is placed proximate to the involved breast taking into account the scar position on the skin
and other relevant clinical information about
the tumor location. Geometrical parameters of
the template are recorded and its position is
marked on the skin (Fig. 2). Preimplant CT
imaging is performed, and the cavity is outlined in axial slices and the target volume is
created according to the contouring protocol.
Then, using 3-D rendering, the patient is
rotated in the needles eye view, and the
target volume is projected on the rendered
template with the holes. By visual inspection,

the holes covering the target volume are identified, and their coordinates recorded (Fig. 3).
The next day, another more rigid template,
geometrically identical to the first, is placed
proximate to the breast in the same position
using the skin marks and template parameters.
Then, using the predefined coordinates, the
needles are inserted into the breast and are
later replaced with plastic catheters. Additional
CT images are acquired for planning, and the
cavity, target volume, and organs at risk are
outlined. The catheters are reconstructed using
the CT and dose planning is performed.
According to the target definition rules used in
the GEC-ESTRO APBI trial, the PTV is
defined as the expansion of the contoured cavity (including surgical clips) in each direction
with an individual margin of 2.0 cm minus the
actual width of the pathological surgical margin. The expansion of the PTV is limited to
0.5 cm below the skin and at the pectoral fascia
(Figs. 4 and 5). When inadequate target coverage is obtained by the catheters, a few additional catheters are implanted manually by
freehand technique. Obviously, in this case
new CT imaging is taken for planning.

Standards
A good implant in interstitial BT is characterized

by adequate dose coverage, high-dose
homogeneity inside and steep dose falloff outside
the target volume. The evaluation of a plan can be
done in qualitative and quantitative manner. In
classical BT, the plan evaluation was limited to
having dose values in reference points and
looking at 2-D dose distributions related to
catheters/applicators. The use of these evaluation
methods is still recommended, but in modern BT
additional tools are now available to assess the
quality of the implant. The 3-D dose calculation
algorithm and real 3-D anatomical information
about the patient make it possible to use the
target- and organ-related DVH and volumetric

Fig. 2 CT-compatible
plastic template on the
breast (a) and its
marked position on the
skin (b)
151
parameters. This means that the treatment

planning and plan evaluation have to be based on
the real 3-D volume of the PTV and organs at
risk. From the DVH, a given amount of a volume
receiving a certain dose can be quantitatively calculated and from those data different quality indices can be determined, which serve as objective
and quantitative measures of the accuracy and
quality of the implant.
3.1
Parameters Related
to Implant Geometry
In interstitial BT, high-dose regions occur in

proximity of the radioactive source(s), which is
a consequence of a basic geometrical phenomenon: the inverse-square law. Due to the highdose gradient around the sources, it is difficult
to achieve a uniform dose distribution in the
152
Fig. 3 Needles eye

view of the template
with patient anatomy.
The projection of the
target volume (red wire
frames) to the front
side of the template
helps to identify the
holes to be used for
inserting needles.
Fig. 4 PTV definition on postimplant CT images for multicatheter APBI. Cavity, red line; expanded tumor bed,
black line; final PTV, green line. The final PTV is defined
excluding the pectoral muscle and a 0.5-cm rim of tissue

below the skin
target volume, however with appropriate source

placement; a relatively uniform dose distribution can be obtained. For quantitative dose
assessment of interstitial implants, the dose
nonuniformity ratio (DNR) was introduced [66]
as the ratio of the high-dose volume to the reference volume. By definition, DNR = V1.5 PD/VPD,
where the reference volume (VPD) is the volume
receiving equal to or greater dose than the
prescribed dose (PD), the high-dose volume

(V1.5 PD) is a volume that receives equal to or
greater dose than the 1.5 PD. For a specific
implant configuration, the reference isodose can
be selected in such a way that the DNR is minimal, resulting in an optimal dose distribution in
terms of dose uniformity. The DNR as a quantitative parameter for evaluating dose uniformity
is always specific to the implant configuration
153
Fig. 5 Dose distribution

on postimplant CT image.
PTV, Thick red line; 100 %
(reference) isodose, thin
red line; 50 % isodose,
green line; 150 % isodose,
yellow line; 200 % isodose,
blue line
and the relative isodose line selected for prescription, but it does not depend on the absolute
value of the dose prescription. Because of its
simplicity and clinical usefulness, the concept
of DNR has been widely accepted and used. In
breast implants, the DNR is expected to be in
the range of 0.20.35.
3.2
Parameters Related to Target

Volume
For a CT-based plan, after delineation of the target volume and critical organs, a target- and
organ-related DVH can be calculated, and additional parameters can be defined for plan evaluation [65, 66]. By definition Vxx is the volume of
tissue treated to at least xx% of the prescribed
dose. Note that the volume can be of the PTV, the
breast, or normal tissue. The coverage index (CI)
is the fraction of the PTV receiving a dose equal
to or greater than the PD. From this definition it
follows that V100 = 100 CI, if V100 relates to
the target volume. The homogeneity index (HI) is
the fraction of the PTV receiving a dose between
100 and 150 % of the PD. In case the homogeneity is not restricted to target volume, but to the
whole implant, the term of dose homogeneity
index (DHI) is used instead of HI [66].
By
definition,
DHI = (V100V150)/V100.
Sometimes the overdose volume index (OI) is
also reported, which is the fraction of the PTV
receiving a dose equal to or greater than twice the
PD. Additional dose parameters (e.g., D100,
D90) are recommended to use for quantitative
plan evaluation. D100 is the maximal percentage
dose that irradiates the full PTV (same as minimal target dose); D90 is the percentage dose that
irradiates 90 % of the PTV.
For quantifying the conformality of dose distribution, the conformal index (COIN) was
defined [67] as follows: COIN = c1 c2, where
c1 = PTVref/VPTV and c2 = PTVref/Vref. The PTVref is
the volume of the PTV receiving a dose equal to
or greater than the reference dose (prescribed
dose). The VPTV is the volume of the PTV and Vref
is the volume receiving a dose equal to or greater
than the reference dose. The COIN takes into
consideration the coverage of the PTV by the reference dose (c1) and also the unwanted irradiation of normal tissue outside the PTV (c2). In an
ideal case, both coefficients (c1 and c2) are equal
to 1. In real situations, this never happens and
therefore the COIN value is less than 1. The best
dose distribution, in terms of conformality, is
obtained when the COIN is maximal. In breast
implants the COIN for a good implant is expected
to be larger than 0.5.
154
3.3
Plan Evaluation in Clinical

Studies
No commonly accepted parameters exist for

evaluating interstitial breast implants. Various
metrics and indices are used in the literature
depending on the complexity of the planning
method. Table 3 shows the parameters used for
reporting dosimetry of breast implants in two
large, multicentric, randomized APBI studies.
Note that in the GEC-ESTRO study, the DHI is
calculated for the target volume. According to
the definition of the DNR and the DHI, they are
complementary parameters (DNR = 1 DHI).
The use of mean central dose (MCD) and
V1.5 MCD (high-dose volume) is recommended
by ICRU 58 [68].
Although the quantitative dosimetric measures of implants are frequently used in clinical
trials, their correlation to clinical outcome (local
control, late side effects) is still unclarified. More
clinical research is needed to find which
parameters should be calculated and reported to
characterize the optimal implant. Furthermore,
due to the diversity of dose prescriptions (to
reference point/points, isodose line or DVHbased), any comparison of the dosimetric and
clinical results from different institutions has to
be made cautiously.
Results
4.1
Results of Interstitial Implants

as a Boost After WBI
Only a few reports compared the outcome in

patients treated with interstitial BT or externalbeam boost (Table 4) [1, 2224, 26, 2830, 35
37, 69]. In the classical trial of the Institut Curie,
women with 37-cm breast cancer treated by
irradiation alone were randomized to 192 Ir BT
versus 60Co teletherapy boost after WBI [1]. The
8-year LR rate was significantly lower with LDR
BT compared to external-beam boost (24 % vs.
39 %; p = 0.02). However, in the postoperative
setting, similar local control and cosmetic results
have been reported for women boosted either
Table 3 Quantitative dose and volume parameters used

for reporting multicatheter breast brachytherapy implants
in the American and European multicentric randomized
APBI trials
For implant
For PTV_EVAL
For skin
For breast
NSABP B-39/RTOG
0413
GEC-ESTRO
DHI
DNR, MCD,
V1.5 MCD
V90
V90, V100,
V150, DHI,
COIN
Dmax
Dmax
V50, V150, V200
DHI dose homogeneity index, DNR dose nonuniformity

ratio, MCD mean central dose, COIN conformal index
with interstitial implants or electrons/photons. In

the EORTC boost trial, the 20-year cumulative
incidence of LR was 9.9 % for the 1640 patients
who received an electron boost, 7.8 % in the 753
patients who received a photon boost, and only
6.2 % in the 225 patients who had an interstitial
LDR BT boost [22]. The difference was not significant (p = 0.094); however the trial was not
powered to detect the possible difference in local
control between different boost modalities.
Recently, Knauerhase et al. [36] reported that
a median dose of 10 Gy HDR BT boost yielded
significantly lower 10-year actuarial LR rate
compared to external-beam boost (5.9 % vs.
12.5 %; p = 0.023). The long-term results of several other (mainly European) clinical studies
proved that HDR BT used either as a single fraction of 712 Gy or as a fractionated boost was
safe and yielded excellent local control [3039,
47, 70, 71] (Table 5).
4.2
Results of Interstitial Implants

as Sole APBI
4.2.1 Early APBI Brachytherapy Trials

Several European and American centers pioneered the use of different APBI regimens for
unselected patients in the 1980s and early
1990s [1215, 4143]. However, results in all
but one of these early studies were poor, with
high LR rates (Table 6). The high rates of
local failure seen in these early APBI studies
155
Table 4 Results of comparative studies with different boost (brachytherapy vs. external beam) techniques after wholebreast irradiation
Institution/study
Saarbrcken [35]
Institut Curie,
Paris [1]
Thomas Jefferson [26]

Hpital Tenon,
Paris [26]
Mallinckrodt Institute
of Radiology [69]
WBH, Michigan [28]
Tufts University [29]

Budapest [23, 24]
EORTC [22]
TMH, Mumbai [30]
University of
Rostock [36]
Technique
HDR
ELE
LDR
Patient
no.
202
91
126
Boost
dose (Gy)
1215
1215
2025
Median
FUP
(years)
>3
>3
8.1
Cobalt-60
129
1136
8.1
LDR
ELE
LDR
654
416
169
1520
20
1525
3.3
3.3
6.7
ELE
161
520
6.9
LDR
ELE
LDR (I-125)
119
487
87
1020
1020
15
5.6
5.6
3.8
LDR
(Ir-192)
ELE
190
15
6.3
108
1015
4.2
Photons
15
1015
4.5
LDR
ELE
HDR
ELE
LDR
ELE
Photons
HDR
LDR
ELE
HDR
127
87
66
237
225
1640
753
153
383
460
75
20
20
814.25
16
15
16
16
10
1520
15
812
>6
>6
5
5
17.2
17.2
17.2
3
6
2.75
7.8
ELE +
photons
181
614
7.8
5-year LR
% ( n)
6.4a
8.8a
24
(8-year)b
39
(8-year)b
7
8
8.1
(10-year)
13.5
(10-year)
6.7
6.2
3
(8-year)
9
(8-year)
9
(8-year)
0
(8-year)
3.9
3.2
8.5
5.6
6.2a
9.9a
7.8a
8
10
7
5.9
(10-year)
12.5
(10-year)
Exc./good
p-value cosmesis % p-value
NR
85
NA
NR
0.02
71
0.6
75
0.21
0.32
91
95
61
NS
0.001
83
NS
0.46
82
80
94
NS
0.59
88
90
82
0.62
0.43
0.094
0.43
0.023
90
78
90
86
NR
NR
NR
83
84
69
NR
0.001
0.29
NA
<0.001
<0.00001
NA
NR
FUP follow-up period, LR local recurrence, LDR low dose rate, HDR high dose rate, ELE electrons, EORTC European
Organisation for Research and Treatment of Cancer, TMH Tata Memorial Hospital, WBH William Beaumont Hospital,
NS not significant, NR not reported, NA not applicable
a
Crude rate
b
Patients treated with radiotherapy alone
reflect inadequate patient selection criteria

and/or suboptimal treatment technique and
lack of appropriate quality assurance (QA)
procedures.
Uzsoki Hospitals Cobalt-Needle APBI

Study
One of the first prospective APBI studies using
interstitial implants was conducted in Hungary at
156
Table 5 Results of HDR brachytherapy boost series
Institution
Saarbrcken [35]
Linz [32]
Paris [33]
Virginia
C. University [37]
Barcelona [34]
Wien [39]
Patient no.
202
212
108
18
RT scheme (dose
[Gy] fraction no.)
1215 1
10 1
52
2.5 6
Median FUP
(years)
>3
5.2
3.75
4.2
294
274
22.5 811
712 1
5.8
8.7
TMH, Mumbai [30]

Valencia [70]
Brno [38]
Rostock [36]
153
125
215
75
10 1
4.4 3
812 1
812 1
3
7
5.8
7.8
Budapest [5]
100
7.8
Madrid [71]
210
4-4.75 3; 6.4 2;
810.35 1
7x1
Valencia [70]
167
71
7.7
All patients
2153
7.1
38.7
5-year LR %
6.4a
4.6
5.1
0
Annual LR %
NA
0.92
1.02
0
Exc./good
cosmesis %
85
78
63
67
9 (9-year)
3.9
(10-year)
8
4.2
1.5
5.9
(10-year)
7 (8-year)
1.00
0.39
96
38
1.6
0.84
0.30
0.59
83
77
73
NR
0.87
57
0.53
85
0.49
97
01.6
3897
5.3
(10-year)
4.9
(10-year)
09
RT radiotherapy, FUP follow-up period, LR local recurrence, TMH Tata Memorial Hospital, NA not applicable, NR not
reported
a
Crude rate
Table 6 Results of early interstitial brachytherapy APBI trials
Institution
Uzsoki Hospital [43]
Guys Hospital
I [13, 14]
Guys Hospital
II [15]
Florence Hospital [12]
Royal Devon/Exeter
Hospital [41]
London Regional
Cancer Center [42]
All patients
RT scheme (dose
[Gy] fraction
Dose rate no.)
MDR
50 1
LDR
55 1
Median FUP
(years)
12
6
Crude LR %
(n)
24 (17 of 70)
37 (10 of 27)
Cosmesis exc./
Annual LR % good %
2
50
6.2
83
MDR
11 4
6.3
18 (9 of 49)
2.9
81
LDR
HDR
5060 1
20 2; 8 4;
66
3.72 10
4.2
1.5
6 (7 of 115)
16 (7 of 45)
1.4
10.7
NR
95
7.6
15 (6 of 39)
100
1.512
16 (56 of
345)
1.410.7
50100
HDR
APBI accelerated partial-breast irradiation, RT radiotherapy, FUP follow-up period, LR local recurrence, MDR medium
dose rate, LDR low dose rate, HDR high dose rate, NR not reported
the Uzsoki Hospital between 1987 and 1992 [43].

Due to the limited availability of modern teletherapy equipment and the lack of 192Ir wires in
Hungary, special 60Co sources were designed and
manufactured to allow manual afterloading of
interstitial BT catheters. During this period, 70

patients were treated with these needles following BCS, without use of WBI. Any patient with a
pathological T1 or T2 tumor that was clinically
unifocal was eligible. Two to eight (median 5)
157
catheters with a fixed 4-cm active length were

implanted into the tumor bed in a single plane. A
dose of 50 Gy was prescribed at 0.5 cm from the
surface of the sources, given in a single session of
1022 h at a dose rate of 2.35.0 Gy per hour.
The volume included within the reference isodose surface was quite small (median: 36 cm3).
Updated 12-year results of this series showed that
the crude LR rate was 24 %, with 59 % of patients
having grade 3 or 4 complications. Unfortunately,
at that era most patients did not have preoperative
mammographic evaluation, and the vast majority
of pathology reports did not contain such important information as pathological tumor size and
the presence of multifocality. Other important
pathological factors were not assessed, such as
pathological axillary node status (unknown for
80 % of patients) and microscopic marginal status (unknown for all patients). Hence, perhaps
most of the patients treated in this study would
not at all be considered eligible for breastconserving therapy today. Therefore, it is likely
that the high rate of LR in this study was due to
having persistent (not recurrent!) tumor due to
inadequate patient selection criteria and radiological and pathological evaluation, as well as a
very small and inadequate implant volume [72].
The high rate of toxicity may have resulted from
giving a high total dose (86134 Gy LDR equivalent dose) delivered within a short overall treatment time without fractionation. Thus, indeed it
was an unfortunate use of unfractionated
medium-dose-rate (MDR) BT. Despite its
obvious limitations, the pioneering experience of
the Uzsoki Hospital subsequently served as a
basis for the development of more successful
APBI series at the Hungarian National Institute
of Oncology, Budapest, carried out subsequently
[4648].
around the tumor bed. The dose prescription was

based on the Paris dosimetry system with a dose
of 55 Gy given over 56 days using manually
afterloaded 192Ir wires. With a median follow-up
of 6 years, 10 of 27 patients (37 %) experienced
recurrence in the treated breast [14].
A second Guys Hospital study enrolled 50
patients between 1990 and 1992 [15]. Patient
selection criteria and surgical and implant
techniques were similar to the first series. An
MDR remote-controlled afterloading system
employing 137cesium was used to give a total dose
of 45 Gy in 4 fractions over 4 days. At a median
follow-up of 6.3 years, 8 of 49 patients (18 %)
developed an in-breast relapse.
It is to be noted that the surgical technique and
patient selection criteria used in these studies
were far from optimal. No attempt was made to
achieve a wide excision either grossly or
microscopically. As a consequence, the surgical
margins were involved in 56 % of patients in the
first study and in 43 % of patients in the second
one. Furthermore, in the first study, 41 % of
patients had tumors containing EIC, and in both
studies 44 % had positive axillary lymph nodes.
Guys Hospital Studies

Fentiman et al. [1315] also explored the
feasibility and limitations of partial-breast BT in
two consecutive pilot trials performed at the
Guys Hospital, London, UK. In the first study,
conducted in 19871988, 27 patients were treated
with LDR implants using rigid needles [13, 14].
The target volume included a 2-cm margin
Florence Series
Between 1989 and 1993, Cionini et al. [12] in
Florence, Italy, treated 115 patients with
T12 N01 tumors with quadrantectomy, axillary
dissection, and LDR BT to the entire quadrant,
giving a dose of 5060 Gy using 192Ir implants.
Young patients, patients with positive or unknown
margins, and patients with infiltrating lobular
carcinoma were included in the study. Patients
with positive axillary nodes (38 %) received
chemotherapy or tamoxifen. The 5-year actuarial
LR rate was 6 %.
Royal Devon/Exeter Hospital Series
In a pilot study performed at the Royal Devon
and Exeter Hospital in the United Kingdom,
fractionated HDR interstitial BT was used to treat
the involved quadrant after tumor excision in 45
patients [41]. Patients selected for BT alone had
tumors smaller than 4 cm, grade 1 or 2 tumors,
and clear or close margins. Three different
fractionation schedules were used: 20 Gy given
158
in 2 fractions, 28 Gy given in 4 fractions, and

32 Gy given in 6 fractions. The crude LR rate was
15.6 % at a short follow-up of 18 months.
However, this study was also limited by the
surgical techniques and pathological reports
used, as axillary dissection was not performed
routinely, and in many cases detailed histologic
findings were not available.
London Regional Cancer Centers
Pilot Study
One of the first APBI studies utilizing fractionated
HDR BT was conducted in Canada [42]. Between
1992 and 1996, 39 patients with T12 breast
cancers received 37.2 Gy in 10 fractions over 1
week prescribed to a small volume (median:
30 cm3) encompassing the surgical clips only.
With a median follow-up of 91 months, the 5-year
actuarial LR rate was 16.2 %. There were 6 breast
recurrences, of which 3 occurred outside the
implanted volume. However, this study has been
criticized for inappropriately limiting the target
volume to the boundaries of the excision cavity
without adding any safety margin to sterilize
possible residual tumor foci in the 12-cm
vicinity of the tumor bed [73].
4.2.2
Contemporary APBI
Brachytherapy Trials
Based on the controversial results of earlier
studies, several groups created APBI trial
protocols incorporating more strict patient
selection criteria and systematic QA procedures.
As a result, the outcomes of these studies have
been much improved (Table 7) [4, 1618, 40,
4446, 4850, 56, 7480].
Ochsner Clinic Experience
The first group in the USA to evaluate the
feasibility of APBI using multicatheter BT was
King et al. [17] at the Ochsner Clinic in New
Orleans. Between 1992 and 1993, 50 patients
(with 51 breast cancers) were treated with either
45 Gy LDR BT (n = 25) or 32 Gy HDR BT
(n = 26) given in 8 fractions of 4 Gy. All patients
had tumors <4 cm with negative margins. Patients
with negative or up to 3 positive axillary nodes
were eligible. Wide-volume implants were used
to encompass the excision cavity with 2-cm

margins in each direction. At a median follow-up
of 75 months, only 1 breast recurrence (2 %) and
3 regional nodal failures (6 %) were observed.
The authors compared the outcome of their
patients with a matched control group of 94
patients who met the eligibility criteria for APBI
but were treated with conventional WBI during
the same time period. The two groups were
similar for LR rates, cosmetic results, and grade
3 side effects.
William Beaumont Hospital (WBH)
Experience
One of the largest experiences using multicatheter
BT to deliver APBI was published by the WBH
group from Royal Oak, Michigan [9, 51].
Between 1993 and 2001, 199 consecutive patients
were treated with 50 Gy interstitial LDR (n = 120)
or HDR (n = 79) BT. In the latter group, a total
dose of 32 Gy in 8 fractions (n = 71) or 34 Gy in
10 fractions (n = 8) was delivered. Eligibility
criteria included age greater than 40 years,
infiltrating ductal carcinoma less than 3 cm in
diameter, negative surgical margins, and up to
13 positive axillary nodes. Patients with an EIC,
pure infiltrating lobular histology, pure ductal
carcinoma in situ (DCIS), or clinically significant
areas of lobular carcinoma (LCIS) in situ were
excluded. All implants were designed to irradiate
the lumpectomy cavity plus at least a surrounding
12-cm margin. According to the last updated
report, at a median follow-up of 10.7 years, a
total of 10 ipsilateral breast failures (5 %) were
observed, translating into a 10-year actuarial LR
rate of 5 % [51]. The results of BT patients were
compared with those in a matched cohort of 199
patients treated with conventional WBI at the
same institution. There were no statistically
significant differences in the 5- and 10-year actuarial rates of LR or regional recurrence.
Hungarian National Institute of Oncology
(HNIO) Studies
Between 1996 and 1998, 45 selected patients
with early-stage invasive breast cancer were
treated with APBI using interstitial HDR implants
at the HNIO, Budapest [40, 46, 47]. Patients were
159

Table 7 Results of contemporary interstitial brachytherapy APBI trials with a median FUP of 4 years
RT scheme (dose
[Gy] fraction no.)
4.33 7; 5.2 7
5060 1
Median FUP
(years)
Crude LR % (n)
13.8
11.1 (5 of 45)
11.2
12.0 (6 of 50)
Annual LR %
0.80
1.07
10.7
5.0 (10 of 199)
0.47
HDR
PDR
HDR
LDR/HDR
LDR/HDR
LDR
PDR/HDR
50 1/4 8;
3.4 10
5.2 7
50/0.83a
3.4 10
45 1/3.4 10
45 1/4 8
4655 1
50/0.6a/4 8
10.2
7.2
7
6.7
6.25
5.6
5.25
5.7 (5 of 88)
6.0 (3 of 50)
9.1 (3 of 33)
6.1 (6 of 99)
2 (1 of 51)
0 (0 of 11)
2.9 (8 of 274)
0.56
0.83
1.30
0.91
0.32
0
0.55
HDR
3.4 10; 4 8
5.1
1.4 (1 of 70)
0.27
HDR
HDR
HDR
HDRb
48
3.4 10
6 6; 6 7
4 8; 3.4 10
5
4.4
4.3
4
413.8
3.0 (3 of 100)
3.8 (1 of 26)
5.0 (1 of 20)
2.9 (8 of 273)
4.4 (61 of 1389)
0.60
0.86
1.15
0.72
01.30
Institution/study
Budapest phase II [40, 47]
Massachusetts General
Hospital [77]
WBH, Michigan [55]
Dose rate
HDR
LDR
Budapest phase III [48]

rebro Medical Centre [45]
Tufts University, Boston [16]
RTOG 9517 [44]
Ochsner Clinic [17]
Ninewells Hospital [51]
German-Austrian phase
II [18]
University of Nice Sophia
Antipolis [75]
University of Perugia [74]
University of Navarra [76]
Osaka Medical Center [78]
Wisconsin University [49]
All patients
LDR/HDR
APBI accelerated partial-breast irradiation, FUP follow-up period, LR local recurrence, HDR high dose rate, LDR low
dose rate, PDR pulsed dose rate, WBH William Beaumont Hospital, RTOG Radiation Therapy Oncology Group NR not
reported
a
Total dose/pulse dose
b
26 pts. (9.5 %) were treated with the MammoSite applicator
eligible for sole BT if they met all of the following conditions: unifocal tumor, tumor size
2.0 cm (pT1), microscopically clear surgical
margins, pathologically negative axillary nodes
or only axillary micrometastases (pN1mi), histologic grade 1 or 2, and technical suitability for
breast implantation. Exclusion criteria were pure
DCIS or LCIS (pTis), invasive lobular carcinoma,
and the presence of EIC. The planning target volume (PTV) was defined as the excision cavity
plus a margin of 12 cm. A total dose of 30.3 Gy
(n = 8) or 36.4 Gy (n = 37) in 7 fractions over 4
days was delivered to the PTV. The 7-year results
(and later the 12- and 15-year update) of this
study were reported, including comparison with
results of a control group treated during the same
time period with conventional breast-conserving
therapy [40, 46, 47]. The control group comprised
80 consecutive patients who met the eligibility
criteria for APBI, but were treated with 50 Gy
WBI with (n = 36) or without (n = 44) 1016 Gy

tumor bed boost. The 12-year actuarial rate of LR
was not significantly different between patients
treated with APBI (9.3 %) and WBI (11.1 %).
There were no significant differences in either the
12-year probability of disease-free survival (75 %
and 74 %, respectively), or cancer-specific
survival (91 % and 89 %, respectively).
Based on the encouraging results of the first
HNIO study, a randomized study was conducted
between 1998 and 2004 at the same institution in
Budapest [48]. Initial eligibility criteria were
similar to those for the previous study, although
following the publication of the EORTC boost
trial in 2001, patients aged 40 years or younger
were excluded. In addition, the trial allowed
patients with breasts technically unsuitable for
performing interstitial implantation to enroll and
be treated with an external-beam (EB) approach.
By May 2004, 258 eligible patients had been
160
randomized to receive either 50 Gy WBI (n = 130)

or partial-breast irradiation (PBI, n = 128). The
latter consisted of either 36.4 Gy (given over 4
days using 7 fractions of 5.2 Gy) with HDR
multicatheter BT (n = 88) or limited-field electron
irradiation (n = 40) giving a dose of 50 Gy in 25
fractions. According to the last updated report,
there has been no significant difference in the
10-year actuarial rate of LR (APBI: 5.9 % vs.
WBI: 5.1 %), disease-free (85 % vs. 84 %),
cancer-specific (94 % vs. 92 %), or overall
survival (80 % vs. 82 %) between the two
treatment arms [48].
rebro Series
The first APBI study using PDR BT was begun in
December 1993 at the rebro Medical Centre in
Sweden [45]. Inclusion criteria included age 40
years or older with a unifocal breast cancer
measuring 5 cm or less without an EIC which
was excised with clear inked margins and up to
three positive axillary lymph nodes. Freehand
plastic tube implants were used to cover the PTV
defined as the excision cavity plus 3-cm margins.
Fifty patients were treated to a total dose of
50 Gy using pulses of 0.83 Gy delivered over 5
days. At a median follow-up time of 86 months,
the 7-year actuarial LR rate was 4 %.
German-Austrian Multicentric APBI Trial
In the year 2000, two German (Erlangen and
Leipzig) and two Austrian (Vienna and Linz)
institutions decided to start the first European
multi-institutional phase II trial to investigate the
efficacy and safety of HDR/PDR multicatheter
APBI [18]. The four participating centers
recruited 274 patients between 2000 and 2005.
Patients were eligible for APBI, if they had a
tumor diameter 3 cm, complete resection with
clear margins 0.2 cm, pathologically negative
axillary lymph nodes or singular nodal
micrometastasis (pN1mi), hormone receptorpositive tumors, and patient age 35 years.
Patients were excluded from the protocol if they
showed a multicentric invasive growth pattern
and had poorly differentiated tumors, residual
microcalcifications, EIC, or lymph vessel
invasion. Among the 274 patients, 175 (64 %)
received PDR and 99 (36 %) HDR BT. Prescribed

dose in the PDR BT group was 49.8 Gy in 83
pulses of 0.6 Gy each hour. Prescribed dose for
HDR BT was 32 Gy in 8 fractions of 4 Gy, twice
daily. Total treatment time for both groups was 5
days. The PTV was confined to the tumor bed
plus a safety margin of 23 cm in each direction.
According to the last update of this study, 8
patients (2.9 %) had developed ipsilateral breast
recurrence after a median follow-up of 63
months, yielding a 5- and 8-year actuarial LR
rate of 2.3 % and 5.0 %, respectively.
Radiation Therapy Oncology Group
(RTOG) 9517 Phase II APBI Trial
Based on the success of single-institution phase
III APBI studies, the RTOG conducted a multiinstitutional phase II trial investigating the use of
multicatheter BT as the sole method of RT after
BCS [44]. Eligibility criteria included unicentric
infiltrating non-lobular breast carcinomas 3 cm
that had been resected with clear margins, with
03 positive axillary nodes without extracapsular
extension. Ineligibility criteria included evidence
of EIC or any lobular component. Between 1997
and 2000, 99 eligible patients have been enrolled
from 11 institutions. Two-thirds of patients
(n = 66) received HDR BT with a prescribed dose
of 34 Gy in 10 fractions, and one-third (n = 33)
were treated with 45 Gy LDR BT. The PTV was
defined as a 2-cm margin peripheral to the cavity
and 1 cm anteriorly and posteriorly. At a median
follow-up of 6.7 years, the estimated 5-year LR
rate for the entire cohort was 4 % (3 % in the
HDR and 6 % in the LDR groups). It is to be
noted that patients with all ages were eligible for
the study. Out of the six LRs, four occurred in
patients younger than 50 years. The crude rate of
LR for patients below and above the age of 50
years was 19 % and 2.6 %, respectively.
University of Wisconsin Experience
In the prospective APBI study of the University
of Wisconsin, eligibility criteria similar to the
RTOG 9517 trial were used [49]. Between 2000
and 2005, 273 patients were treated with a total
dose of 3234 Gy in 810 twice-daily fractions
within 45 days using HDR BT. The majority of
161
patients (n = 247) were treated using multicatheter

BT, while the others (n = 26) with the
MammoSite applicator. For study purposes, the
authors separated their patients into two groups:
high-risk patients, who satisfied one or more of
the so-called high-risk criteria as age <50 years,
estrogen receptor negative, and/or positive lymph
nodes (n = 90), and low-risk patients, who
comprised the remainder of the cohort (n = 183).
At a median follow-up of 4 years, the actuarial
5-year LR rate in the high- and low-risk groups
was 6.4 % and 2.2 %, respectively (p = 0.29).
to be assessed and statistically tested is nonrelevant non-inferiority of the experimental

treatment. Secondary end points address overall,
disease-free, and distant metastasis-free survival,
contralateral breast cancer, early and late side
effects, cosmesis, and quality of life. Eligibility
criteria included unifocal DCIS or invasive carcinoma of the breast, tumor size 3 cm, microscopic negative margins of at least 0.2 cm (0.5 cm
for DCIS or invasive lobular carcinoma), no EIC,
no lymphovascular invasion, no more than one
micrometastasis in axillary lymph nodes
(pN1mi), and patient age 40 years. Patients
were stratified before randomization according to
the treatment center, having DCIS or invasive
carcinoma, and menopausal status. The QA
program for partial-breast BT included
preimplant PTV definition by surgical clips and/
or preimplant CT image-based preplanning of the
implant geometry. The PTV was defined as the
excision cavity plus 2-cm margin minus the
minimum clear pathological margin. Postimplant
CT scans were mandatory for the documentation
of target coverage and dose homogeneity.
Acceptable treatment parameters for CT imagebased treatment planning included:
Other Multicatheter APBI Experiences

Additional experiences with multicatheter APBI
have been published by other groups with smaller
sample sizes and/or less mature follow-up [16,
50, 7479] (see Table 7). In the majority of these
trials, similar local tumor control rates were
achieved as in other breast-conserving series
using conventional WBI.
4.2.3
Multicentric Randomized APBI

Trials
In addition to the Hungarian randomized APBI
study, to date seven prospective phase III clinical
trials have been activated to compare the efficacy
of APBI to conventional WBI. Among these, two
protocols (the European GEC-ESTRO and the
American NSABP/RTOG trials) use BT for the
delivery of APBI in the investigational arm [7, 9].
The GEC-ESTRO Multicentric Randomized
APBI Trial
Based on the success of the Hungarian and
German-Austrian APBI studies, a multicentric
phase III APBI protocol has been developed by
the Breast Cancer Working Group of the GECESTRO [7]. Only interstitial HDR or PDR BT
was allowed for the APBI arm of this European
multicentric phase III trial. Between April 2004
and July 2009, 1188 patients were enrolled at 16
centers from 7 European countries. Patients in
the control group were treated with 50 Gy WBI
plus a 10 Gy electron boost. Patients in the APBI
arm were treated with HDR or PDR multicatheter
BT. The primary end point of the study is LR as a
first event within 5 years. The scientific hypothesis
DVH analysis of target coverage confirming

that the prescribed dose covers 90 % of the
PTV (coverage index 0.9)
DNR 0.35
Maximum skin dose <70 % of the prescribed
dose
The GEC-ESTRO APBI trial is financially
supported by the grant from German Cancer Aid
(Deutsche Krebshilfe) for a study period of 4
years between 2005 and 2009. It is anticipated
that the 5-year results will be published in late
2015.
NSABP B-39/RTOG 0413 Multicentric
Randomized APBI Trial
The American multicentric phase III trial investigating APBI was initiated in March 2005 by the
National Surgical Adjuvant Breast and Bowel
Project (NSABP) together with the RTOG [9].
Patients were randomized between standard
162
WBI and APBI. The latter was delivered with any

of the three techniques: multicatheter HDR BT,
MammoSite BT, or 3-dimensional externalbeam RT. Eligibility criteria included unicentric
DCIS or invasive carcinoma allowing
microscopical multifocality confined to one
quadrant of the breast, tumor size 3 cm, microscopically negative margins by the NSABP criteria (no tumor on inked margins), and no more
than 3 positive axillary lymph nodes (pN0-1a)
without extracapsular extension. In contrast to
the GEC-ESTRO trial, patients below the age of
40 years with tumors excised with close (but
clear) surgical margins or containing an EIC as
well as patients with 13 positive nodes were eligible for the NSABP/RTOG trial. Due to the
rapid enrollment of low-risk patients by multiple
American centers, the original accrual goal (3000
patients) was increased to 4300. In December
2006, the trial closed enrollment to low-risk
patients, thereby limiting further accrual to
patients satisfying one or more of the high-risk
criteria including age <50 years, estrogen
receptor negativity, or 13 positive nodes [49].
The enrollment of 4300 patients concluded in
2013 and the first results are to be published in
2017 (personal communication; Vicini FA).
Unfortunately, only 29 % of patients randomized
to APBI have been treated with BT (23.3 % with
MammoSite BT, and only 5.7 % with interstitial
HDR BT).
Side Effects
and Management
5.1
Acute Side Effects
Acute side effects of interstitial breast BT include

hematoma formation, edema, infection, acute
radiation dermatitis (mainly limited to the needle
puncture sites), and mastalgia [18, 45, 77, 80,
81]. However, the rate and severity of these early
complications are low and clinically negligible.
The rate of perioperative breast infection was
reported in the range of 011 % [45, 47, 48, 80,
81] In the William Beaumont series, 22 of 199
patients (11 %) developed infections, but only 5
of them (2 % of all patients) required surgical

intervention including incision and drainage or
debridement [80]. It is to be noted that a
significantly lower rate of infections occurred
following closed-cavity implant placement
(4.9 %) compared to intraoperative open-cavity
placement (17.5 %; p = 0.005). In other series
using postoperative catheter implantation and
prophylactic antibiotics, breast infections rarely
occurred [18, 47, 48, 81].
5.2
Late Side Effects and Cosmetic

Results
Late side effects of interstitial breast BT include

skin and subcutaneous toxicities [1618, 40, 42,
45, 47, 48, 7477, 79, 8286]. Among these, skin
telangiectasia >1 cm2, moderate and severe
subcutaneous fibrosis, and symptomatic fat
necrosis are clinically relevant which have been
reported in wide ranges in different series
(Table 8).
The rate of telangiectasia is highly dependent
on the dose delivered to the subcutaneous small
vessels beneath the skin [6, 42, 87]. A higher
incidence of late skin side effects occurred in
early BT studies not using any skin dose
constraints or dose optimization [42, 43, 45, 77,
79]. However using strict skin dose constraints
(e.g., <6070 % of prescription dose), the rate of
telangiectasia was reported far below 10 % [18,
40, 47, 84].
Moderate to severe subcutaneous fibrosis was
reported in the range of 454 % in contemporary
series of interstitial breast BT (see Table 8). The
rate of subcutaneous toxicities primarily depends
on the total dose, dose fractionation, dose rate,
overall implant volume (V100 %), and dose
homogeneity (represented by the DNR). Other
factors playing critical roles in the development
of late parenchymal side effects and ultimate
cosmetic results include chemotherapy and
particularly surgery [87]. On the other hand,
asymptomatic fat necrosis is a common adverse
event after breast-conserving therapy, having no
significant clinical relevance in the majority of
cases [16, 83, 85, 86]. In the Budapest randomized
163
Table 8 Late side effects and cosmetic results of contemporary interstitial brachytherapy APBI trials with a median
FUP of 4 years
Institution/study
Budapest phase II [40]
Massachusetts General
Hospital [77]
Budapest phase III [84]
rebro Medical
Centre [45]
Tufts University,
Boston [16]
WBH, Michigan [82]
Ochsner Clinic [17]
Tufts and Virginia
C. Universities [86]
German-Austrian
phase II [18]
University of Nice
Sophia Antipolis [75]
RTOG 9517 [79]
University of
Perugia [74]
London Regional
Cancer Center [42]
University of
Navarra [76]
All patients
Dose rate
HDR
LDR
Median
FUP
(years)
13.8
11.2
G2
telangiectasia
% (n)
4 (2 of 45)
35 (16 of 46)
G2 fibrosis %
(n)
9 (4 of 45)
54 (25 of 46)
Symptomatic fat
necrosis %
22 (10 of 45)
35a (16 of 46)
Exc./good
cosmesis
%
80
67
HDR
PDR
10.2
7.2
8 (7 of 85)
22 (11 of 50)
19 (16 of 85)
26 (13 of 50)
1.2 (1 of 85)
12 (6 of 50)
85
56
HDR
7 (2 of 28)
36 (10 of 28)
52a (17 of 33)
93
LDR/HDR
LDR/HDR
HDR
6.4
6.25
6.1
1.3 (1 of 79)
NR
4 (3 of 75)
8 (6 of 79)
NR
17 (13 of 75)
14 (11 of 79)
4 (2 of 51)
13a (10 of 75)
99
75
91
PDR/HDR
5.25
8 (21 of 274)
14 (39 of 274)
5 (14 of 274)
90
HDR
5.1
1.4 (1 of 70)
6 (4 of 70)
NR
96
LDR/HDR
HDR
5
5
10 (10 of 98)
7 (7 of 100)
31 (30 of 98)
4 (4 of 100)
15 (15 of 98)
1 (1 of 100)
68
98
HDR
22 (6 of 27)
37 (10 of 27)
19a (5 of 27)
100
HDR
4.4
4 (1 of 26)
4 (1 of 26)
NR
87.5
4.413.8
9 (88 of 1003)
17 (175 of 1003)
11 (108 of 963)
56100
APBI accelerated partial-breast irradiation, FUP follow-up period, HDR high dose rate, LDR low dose rate, PDR pulsed
dose rate, WBH William Beaumont Hospital, RTOG Radiation Therapy Oncology Group, NR not reported
a
Symptomatic and asymptomatic fat necroses were reported together
APBI trial, the incidence of fat necrosis was similar after HDR APBI BT and WBI [83]. Among
the evaluated patient-, tumor-, and treatmentrelated variables, only larger bra cup size was
significantly associated with the incidence of fat
necrosis. They also concluded that routine follow-up examinations (including mammography,
US, aspiration cytology, and ultimately breast
MRI) are sufficient for the differential diagnosis
of fat necrosis. They also warned that open
biopsy should be avoided when possible, as core
biopsy and MRI are useful for differentiating fat
necrosis from LR.
To keep the rate of subcutaneous toxicities
(including fibrosis and symptomatic fat necrosis)
low, the overall implant volume should be limited,
and more importantly the high-dose volume
(e.g., V150 % and V200 %) should be minimized

keeping the dose distribution as homogenous as
possible (e.g., keeping the DNR below 0.30 or
DHI above 0.70) [47, 48, 66, 85, 86, 88]. Within
the range of small- to intermediate-volume
implants (up to 160 cm3), neither implant volume
(V100 %), volume of high-dose region (V150 %,
V200 %), or dose inhomogeneity is associated
with an increased risk of subcutaneous toxicities
[45, 47, 83, 84]. However with large-volume
implants (>160 cm3), larger high-dose regions are
correlated with a higher incidence of fat necrosis,
and the absolute volume of the high-dose region
seems to be associated with the risk of subsequent
fat necrosis [85, 86]. As a conclusion, to minimize
late subcutaneous toxicities, image-guided BT and
3-D CT-based planning are suggested to minimize
164
the overall volume of breast implants and control

the volume of hot spots.
Summary and Future

Perspectives of Interstitial
Before the era of breast-conserving therapy, BT

implants were used to treat large inoperable
breast tumors. More recently, interstitial BT has
been used to deliver an additional dose to the
tumor bed after BCS and WBI. Based on the
obvious dosimetric advantages of interstitial
breast implants (over external-beam techniques)
supported by the encouraging results of modern
boost series utilizing stepping-source afterloading
technology, multicatheter HDR/PDR BT remains
a standard treatment option for boosting the
tumor bed after BCS and WBI.
APBI is an attractive treatment approach with
considerable advantages over conventional WBI
opening new prospects for interstitial breast
BT. Contemporary APBI trials using interstitial
BT with strict patient selection criteria and
systematic strict QA procedures resulted in an
annual LR rate of <1 %. Issues of patient
selection, PTV definition, total dose, and
fractionation will be addressed and refined by the
experience obtained from the eagerly awaited
results of the GEC-ESTRO and NSABP/RTOG
multicentric randomized APBI trials.
Development of new standards for 3-D CT
image-based BT treatment planning together
with the implementation of inverse dose planning will further improve the conformity of
dose distribution delivered by multicatheter
implants maximizing the advantage of interstitial breast BT.
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Breast Brachytherapy:
Intracavitary Breast
Brachytherapy
Jaroslaw T. Hepel, David E. Wazer, Frank A. Vicini,
and Douglas W. Arthur
Abstract
Accelerated partial breast irradiation (APBI) represents a more conformal

and convenient method to deliver adjuvant radiation as part of a breastconserving therapy approach. Interstitial multi-catheter brachytherapy
was the first technique developed to deliver APBI, however, the complexity of this implant procedure limited its widespread use to select highvolume centers. The intracavitary brachytherapy (ICB) technique was
introduced to provide a less complex implant and resulted in adoption
across a broader users base. Studies of the initial single-lumen
MammoSite catheter have shown a high rate of local control and goodto-excellent cosmetic outcomes. However, the simplicity of this initial system limited any dosimetric modulation. As a result, implants that were
close to the skin or chest wall were at an increased risk of toxicity and
compromised cosmetic outcome. The next generation of ICB applicators
(Contura, MammoSite ML, and SAVI) utilizes multiple lumens, now
allowing for optimization of the dose distribution resulting in improved
normal tissue sparing.
J.T. Hepel, MD, FACRO (*)

Department of Radiation Oncology, Rhode Island
Hospital, Warren Alpert Medical School of Brown
University, Providence, RI, USA
D.E. Wazer, MD, FACRO, FACR, FASTRO
Departments of Radiation Oncology, Tufts Medical
Center, Tufts University School of Medicine, Rhode
Island Hospital, Alpert Medical School of Brown
University, Boston, MA, USA
F.A. Vicini, MD, FACR

Department of Radiation Oncology, St. Joseph Mercy
Oakland, Pontiac, MI, USA
D.W. Arthur, MD
Department of Radiation Oncology, Virginia
Commonwealth University School of Medicine,
Richmond, VA, USA

DOI 10.1007/978-3-319-26791-3_9
169
J.T. Hepel et al.
170
Introduction
The advent of breast-conserving therapy (BCT)

marks a major advance in the management of
early-stage breast cancer, sparing women the
morbidity and psychosocial impact associated
with mastectomy [1]. The equivalence of BCT
consisting of breast-conserving surgery (BCS)
and radiation therapy compared with more radical surgery has been demonstrated in several
phase III trials [24]. Despite the undisputed efficacy of this treatment approach, the amount of
clinically uninvolved breast tissue surrounding
the lumpectomy cavity requiring irradiation has
never been definitively established. Standard
radiation therapy after BCS has consisted of elective treatment of the whole breast. The addition
of this prophylactic treatment of uninvolved
breast tissue with radiation is generally considered responsible, at least in a large part, for the
acute and chronic toxicity associated with BCT
and for the protracted time required to complete
therapy.
In recognition of these limitations, accelerated
partial breast irradiation (APBI) has been investigated as a possible option for the management of
selected patients with an anticipated low risk of
harboring in-breast microscopic disease remote
from the lumpectomy cavity [5]. APBI incorporates both a reduction of the radiation field to the
region of the surgical bed after BCS and of the
overall radiation treatment time from 6 to 1 week
or less. Thus APBI not only represents a logistically simpler and more practical method for radiation as part of BCT, but also has the potential
advantages of reduced treatment-related toxicities and improved overall quality of life for earlystage breast cancer patients [6].
Interstitial multi-catheter brachytherapy was
the first technique commonly employed to deliver
APBI. As such, the studies using interstitial
brachytherapy have provided the largest group of
patients with the longest follow-up and have
established APBI as an acceptable treatment
option [79]. However, the complexity and reproducibility of the interstitial procedure have lim-
ited the widespread use of this technique,

particularly for lower-volume centers. The intracavitary brachytherapy (ICB) technique was,
therefore, introduced to provide a less complex
implant with increased reproducibility of radiation delivery to the target volume. Since its introduction, ICB has become the most widely used
brachytherapy technique for APBI.
Indications and Patient

Selection
Although ICB is occasionally used for boost

irradiation to the lumpectomy cavity as part of
whole breast irradiation, the invasive nature of
this technique as compared to other simpler
methods limits its utility for this indication to
select complex cases. ICB was developed to
deliver APBI and this remains the predominant
indication.
In addition to target delineation and dose coverage, one of the key components contributing
to the successful application of APBI is patient
selection. Patients with a significant risk of harboring microscopic disease within the breast, but
located outside the stated treatment target (1 cm
beyond the lumpectomy cavity), are not optimal
candidates for APBI [10]. To date, conservative
patient selection criteria have been employed
until more definitive outcomes data become
available. The National Surgical Adjuvant
Breast and Bowel Project/Radiation Therapy
Oncology Group (NSABP/RTOG) and Groupe
Europen de Curiethrapie European Society
for Therapeutic Radiology and Oncology (GECESTRO) are conducting phase III randomized
trials evaluating APBI which will help determine which patients are appropriate for this
approach and better define the breadth of application. Until mature data are available for these
trials, several societies have endorsed conservative patient selection criteria with the goal of
providing guidance and general consistency in
selection of eligible patients [1114]. These are
summarized in Table 1.
Breast Brachytherapy: Intracavitary Breast Brachytherapy

Table 1 Guidelines for appropriate patient selection
for APBI
American Society of Radiation Oncology (ASTRO)
(2009)
Suitable group
Patient factors
Age 60 years
BRCA1/2 mutation not present
Pathologic factors
Tumor size 2 cm
T stage: T1
Margins negative (by at least 2 mm)
Any grade
No LVSI
ER +
Unicentric and unifocal
Histology: invasive ductal or other favorable subtypes
Pure DCIS or EIC not allowed
Associated LCIS is allowed
Nodal factors
N stage: pN0 (i, i+)
Nodal surgery: SN Bx or ALND
Treatment factors
Neoadjuvant chemotherapy not allowed
Groupe Europen de Curiethrapie-European
Society for Therapeutic Radiology and Oncology
(GEC-ESTRO) (2010)
Low risk group
Age 50 years
Histology: invasive ductal or other favorable
subtypes
Invasive lobular carcinoma not allowed
Pure DCIS or EIC not allowed
Tumor size 3 cm
ER + or
Margins negative (by at least 2 mm)
Unicentric and unifocal
No LVSI
Lymph node negative by SN Bx or ALND (pN0)
Neoadjuvant chemotherapy not allowed
American Society of Breast Surgeons (ABSB)
(Update 2011)
Age 45 years
Invasive ductal carcinoma or DCIS
Tumor size 3 cm
Margins negative (no tumor at inked margin)
Lymph node negative by SN Bx or ALND (pN0)
171
American Brachytherapy Society (ABS) (Update
2013)
Age 50 years
Invasive carcinoma (any histology)
DCIS
Tumor size 3 cm
ER + or
Margins negative (no tumor at inked margin)
No LVSI
Lymph node negative
The American Society of Radiation Oncology

(ASTRO) appointed a task force to review available treatment outcomes data from APBI trials and determine the most appropriate patient
selection criteria. This was first accomplished in
2009 and work toward reevaluation with a possible update has begun. The consensus statement
published in 2009 consisted of three categories
suitable, cautionary, and unsuitable [13].
These categories refer to appropriate patient selection for treatment outside the context of a clinical
trial. Patients considered meeting the suitable
criteria for APBI consist of age 60 years, lack
of BRCA 1/2 germ line mutation, invasive ductal histology, tumor size 2 cm, margins microscopically negative by at least 2 mm, estrogen
receptor (ER) positive, unicentric disease, and
pathologically node negative. Patient and tumor
characteristics falling outside these criteria were
delegated to the cautionary or unsuitable categories. These criteria were based on available
outcomes data from predominantly early treatment experiences which were highly selective.
Several recent studies have called into question
these conservative criteria showing no difference
in ipsilateral breast tumor recurrence (IBTR) for
patients in the cautionary and even unsuitable categories [1517]. To incorporate recent
data, the American Brachytherapy Society (ABS)
released an update of their consensus statement
[12]. According to the ABS criteria, patients
deemed acceptable for APBI are patients who
are age 50 years with tumors 3 cm of any invasive histology or DCIS that are either ER posi-
J.T. Hepel et al.
172
tive or negative, and who have negative margins

(no ink on tumor), no LVSI, and negative lymph
nodes. Although patients that do not meet these
criteria have not been definitively shown to have
inferior results with APBI, there is limited experience in treating such patients. Thus, employing
conservative patient selection criteria as supported by the ABS, ASTRO, GEC-ESTRO, and
American Society of Breast Surgeons (ASBS)
remain prudent until definitive data are available.
In addition to patient selection for APBI in general, appropriate APBI technique selection in order
to achieve optimal dosimetry is important in order
to optimize outcomes [18]. The patients comorbidities, body habitus, breast size, tumor location,
and lumpectomy cavity geometric configuration
should all be considered. For the ICB technique, it
is important for the applicator to conform to the
lumpectomy cavity. A collaboration with the breast
surgeon is essential to help create a desirable target
cavity and to avoid certain oncoplastic maneuvers
that can transpose at-risk tissue to remote locations
within the breast away from the lumpectomy cavity. Furthermore, the ability to control and limit the
skin and rib dose is of paramount importance.
Initially, with the use of a single-lumen balloon
catheter, the spacing between the lumpectomy cavity and the skin and the resultant influence on skin
dose, toxicity, and cosmetic outcome was the focus.
With the use of the single-lumen catheter, a minimum skin spacing of 7 mm was required in order to
meet recommended skin dose-volume constraints,
and a lumpectomy cavity to rib spacing of 5 mm
was required in order to meet recommended rib
point dose constraints. With the transition to multilumen catheters, the focus has shifted away from
physical spacing to limiting the dose through 3D
planning platforms and therefore acceptable skin
and rib doses can be achieved despite reduced distance to the skin and/or rib.
Technique and Catheter

Systems
The ICB technique was introduced to provide a

less complex implant technique over placement
of multiple interstitial catheters. The first com-
mercially available device (MammoSite) consisted of a balloon applicator with a single central
lumen for delivery of radiation. The simple single-entry insertion coupled with simple treatment
planning of this device made ICB widely popular
in North America. However, the simplicity of this
initial system possessed significant dosimetric
limitations. This led to the evolution of more
complex devices (Contura MLB, MammoSite
ML, SAVI) to help address these limitations
yet maintain the ease of use of a single-entry
applicator system. Each of these devices will be
reviewed here.
3.1
Single-Lumen Intracavitary
Balloon Catheter
(MammoSite)
The MammoSite breast brachytherapy applicator (Hologic Inc., Bedford, MA, USA) received
clearance by the FDA in 2002 and became one
of the most used forms of APBI with more than
40,000 women implanted to date [19]. This device
is a single-catheter system (Fig. 1) consisting of
an outer lumen that allows for inflation of a balloon at the end of the shaft of the catheter and
a single central lumen allowing the passage of a
high-dose-rate (HDR) afterloaded 192Ir source for
the administration of radiation. The implantation
of the MammoSite device is relatively simple
and reproducible. Implantation can be performed
either at the time of surgery under direct visualization of the lumpectomy cavity (open technique) or postoperatively under image guidance
(closed technique). The closed technique is
recommended as the risk of infection, rate of
persistent seroma formation, and resulting compromise in cosmetic outcome had been shown to
be reduced with this approach [20]. The closed
technique is typically performed 12 weeks postoperatively. Although placement at longer delays
is possible, organization and contracture of the
lumpectomy cavity may result in difficulty of
cavity identification, catheter insertion, and/or
balloon to cavity conformance. Using the closed
technique, the catheter is inserted using image
guidance via ultrasound (US), computed tomog-
173
Fig. 1 (a) MammoSite single-lumen intracavitary balloon catheter. (b) Near-spherical dose distribution prescribed to
1.0 cm from the balloon surface
raphy (CT), or both (Fig. 2). Based on measurements of the lumpectomy cavity on imaging,
an appropriately sized applicator is selected. A
variety of balloon sizes in both spherical and
elliptical shapes have been available for optimal conformity. Using sterile technique and
local anesthesia, the device is inserted utilizing
an accompanying trocar. Insertion can be performed via the lumpectomy scar or via a remote
site. Although less common, the scar-entry tech-
nique provides safe, direct access to the cavity

and provides an ideal orientation, perpendicular
to the skin and chest wall, for the single-lumen
catheter. This orientation allows for the effect of
anisotropy and a degree of dwell position manipulation to protect the skin and rib from excessive
dose if the distance is close [21]. More commonly, the entry point is selected so that the balloon orientation is parallel to the skin and chest
wall. Regardless of preferred style, the entry
J.T. Hepel et al.
174
Fig. 2 Closed cavity balloon catheter insertion technique

using real-time ultrasound guidance and a lateral entry
approach
point should be individualized to the patient and

selected so as to minimize the distance between
insertion site and cavity, allow for optimal geometric conformity of the cavity to the balloon,
and result in a comfortable applicator position for
the patient for the duration of therapy.
After insertion, the balloon is inflated using
saline and radiographic contrast. A planning CT
scan is then performed to evaluate the adequacy
of device placement. This should include
conformality of the balloon surface to the
lumpectomy cavity (>90 %), symmetry of the
balloon applicator (<0.2 cm deviation in any
dimensions), and the adequacy of skin spacing
(0.7 cm). Once proper applicator and balloon
position is established, CT imaging is acquired
for 3D planning. The balloon, skin, chest wall,
and target volume should be contoured. Likewise
the central lumen and source dwell positions
should be identified for planning. The target
volume or planning tumor volume (PTV) consists
of the 1 cm rim of breast tissue around the inflated
balloon applicator. With adequate applicator
placement, this will correspond to the tissue
surrounding the lumpectomy cavity. The PTV
should not extend into the chest wall and should
be limited by 0.5 cm from the skin surface.
Source dwell positions and times are then
determined in order to deliver the prescription
dose to the PTV. Treatment can either be delivered
via a single central source dwell position or via
multiple source dwell positions along the central

lumen. The use of multiple dwell positions
reduces the dose heterogeneity across the
implant, but the clinical implications of this have
not been established [22]. Using either method,
the resulting dose distribution is a near-symmetric
sphere or ellipse. The simplicity of this catheter
system makes treatment planning simple but also
allows virtually no ability to modulate the dose
distribution. Thus, the dose to the skin and chest
wall is purely a function of applicator position
and skin or chest wall spacing. Once the treatment
plan is generated, treatment is delivered using a
HDR Ir-192 source via a remote afterloader. Prior
to each fraction of treatment, the balloon position
and volume should be verified using US, CT, or
fluoroscopic imaging.
3.2
Multi-lumen Balloon
Intracavitary Catheters
(Contura; MammoSite
Multi-Lumen)
The next generation of balloon applicators sought

to improve upon the limitations of the singlelumen MammoSite systems fixed geometry and
inflexibility to sculpt dose. By introducing multiple lumens, these new applicators have a greater
capacity to shape dose through optimization of
source dwell time and position. Two similar
multi-lumen balloon catheters are currently available: Contura MLB (SenoRx Inc, Aliso Viejo,
CA) and MammoSite Multi-Lumen (ML)
(Hologic Inc, Bedford, MA). The Contura catheter has one central lumen surrounded by four
peripheral arched lumens at a 0.5 cm central offset (Fig. 3). The MammoSite Multi-Lumen has
one central lumen surrounded by three peripheral
parallel lumens (Fig. 4).
The insertion technique for the MammoSite
ML and Contura MLB are essentially similar to
that of the single-lumen MammoSite described
above. The Contura catheter does have an additionally vacuum port which can eliminate seroma
fluid or air pockets surrounding the inflated balloon improving conformality of the lumpectomy
cavity to the balloon [23]. Treatment planning for
175
Fig. 3 Contura multilumen balloon catheter
Fig. 4 MammoSite
multi-lumen balloon
catheter
these two multi-lumen catheters allows for optimization of source dwell times among the 45
lumens and thus allows asymmetric dose distributions. This results in the ability to reduce skin or
chest wall dose despite close applicator spacing.
The dosimetric advantages of the Contura
MLB catheter have been evaluated by several
investigators and have been consistently shown to
improve skin and chest wall dose sparing compared to a single-lumen MammoSite catheter
(Fig. 5) [2427]. Arthur et al. performed a preliminary dosimetric analysis of a phase IV trial evaluating the Contura catheter [26]. They reviewed
144 cases and found that 92 % and 89 % of case
met dose restriction to the skin (<125 %) and chest
wall (<145 %), respectively. Even in cases with
<7 mm of skin spacing and <5 mm of chest wall
spacing, most plans met these constraints.
For the multi-lumen catheters, prior to each
treatment, not only is it important to verify
balloon position and fill volume, but the rotational
position of the applicator needs to be verified.
This is typically done using alignment of a skin
and catheter mark which has been shown to result

in a reproducible applicator position [28].
3.3
Multi-lumen Non-balloon
Intracavitary Catheter (SAVI)
The strut-adjusted volume implant or SAVI

(Cianna Medical, Aliso Viejo, CA) is a hybrid,
non-balloon-based, intracavitary brachytherapy
catheter system. This system combines the
dosimetric flexibility of interstitial implants
with the simplicity of a single-catheter entry into
the breast. The SAVI consisting of a central
lumen surrounded by 610 peripherally positioned lumens depending on the selected applicator size (Fig. 6). When initially inserted into
the breast, all the lumens are collapsed together
and catheter insertion is identical to the balloonbased ICB catheters. Upon placement into the
lumpectomy cavity, the peripheral lumens are
expanded to form a cage-like structure that conforms to the lumpectomy cavity. The multiple
J.T. Hepel et al.
176
Fig. 5 Dosimetric comparison of single-lumen versus

multi-lumen balloon catheters for treatment of a
lumpectomy cavity with 0.66 cm skin spacing. (a)
MammoSite single-lumen catheter with 95 % coverage
of the PTV with 95 % of prescription dose resulting in a
maximum skin dose of 4.6 Gy (126 % of prescription).
(b) Contura (MLB) demonstrating the ability to modulate the dose distribution via source dwell positions and
times within the five lumens resulting in 95 % of the
PTV covered by 95 % of prescription dose while reducing the maximum skin dose to 2.9 Gy (85 % of
prescription)
177
Fig. 6 Strut-adjusted volume implant. (a) SAVI multi-lumen intracavitary catheter. Dosimetry images in the (b) coronal and (c) sagittal planes demonstrating ability to modulate dose distribution to conform to the lumpectomy cavity
J.T. Hepel et al.
178
lumens of the SAVI catheter abut the tissue

surrounding the lumpectomy cavity and allow
great flexibility in dosimetric geometry. This
allows for dose distribution that can conform
to irregular target volume configurations and
allows for a greater ability to restrict dose to the
skin and chest wall [29]. However, it is important to note that the SAVI catheter has distinct
dosimetry compared with the balloon-based
ICB systems resulting in distinct dosimetric and
radiobiological consideration for normal tissue
effects. The dosimetry of the SAVI catheter is
in some ways similar to that which is achieved
with interstitial brachytherapy. However, unlike
interstitial implants, the multiple lumens of
the SAVI catheter line the lumpectomy cavity
rather than being positioned with even spacing
throughout the entire target volume. Thus, the
distance from the lumens to the edge of the PTV
is greater with the SAVI catheter than when
using the interstitial catheters. This can result
in higher dose hotspots. Mean V150 (volume
of target receiving 150 % of prescribed dose)
and V200 (volume of target receiving 200 %
of prescribed dose) have been reported to be
22.730.8 cc and 11.614.9 cc, respectively [30,
31]. These values of V150 and V200 are higher
than what is typically seen with balloon-based
ICB catheters but in most cases do not exceed
the values associated with suboptimal cosmetic
outcomes in the interstitial brachytherapy experience [32]. Early clinical experience has been
encouraging, but mature clinical data is needed
for the SAVI catheter to understand the clinical
implications of the distinct radiobiology of this
catheter system [33, 34].
Dosimetric Constraints
and Quality Metrics
The most commonly prescribed dose with ICB

is 34.0 Gy in 10 fraction delivered twice daily
at least 6 h apart over 1 week. Shorter treatment courses delivered in an even more convenient schedule over 2 days (4 fractions) and
even 1 day (2 fractions) are being explored [35,
36]. The intended dose is prescribed to the PTV
margin which consists of the 1 cm rim of tissue around the applicator or lumpectomy cavity
limited by the chest wall and 0.5 cm from the
skin. An acceptable plan will have >90 % of the
prescription dose encompassing >90 % of the
PTV. However, >95 % of the prescription dose
encompassing >95 % of the PTV is desirable.
The maximum skin surface dose and chest wall
dose should be reported. These should be <100
125 % and <145 % of prescription dose, respectively, particularly when using the multi-lumen
catheters. The V150 and V200 should also be
reported. The optimal V150 and V200 have not
been well established for the ICB technique.
Empiric V150 and V200 constraints of <50 cc
and <10 cc are recommended for the balloonbased techniques and <50 cc and <20 cc for the
SAVI device.
Treatment Outcomes
A multi-institutional trial designed to evaluate the

safety and performance of the single-lumen
MammoSite catheter was performed as part of the
regulatory approval process in the United States.
The initial report by Keisch et al. [19] showed the
feasibility and acceptable acute toxicity of this
approach in a cohort of 43 patients. As data matured,
results at 5-year follow-up were reported demonstrating no local or regional failures. The rates of
implant-related infection (9 %) and fat necrosis
(9 %) were acceptable. Seroma formation occurred
in 33 % of patients, of which 12 % were symptomatic requiring aspiration. Overall, good-excellent
cosmetic outcome was observed in 83.3 % of
patients [37]. This trial led to the United States Food
and Drug Administration (FDA) clearance of the
MammoSite device for use in the United States.
A summary of clinical experience with ICB is
shown in Table 2. The two largest published experiences come from a multi-institutional cohort
compiled at Virginia Commonwealth University
(VCU) and the American Society of Breast
Surgeons (ASBS) MammoSite registry trial [20,
38]. The VCU group reported on 483 patients
with a median follow-up of 24 months [20].
Ipsilateral breast tumor recurrence (IBTR) was
179
Table 2 Intracavitary brachytherapy (ICB) single and multi-institutional trials
Institution/study
FDA trial [37]
ASBS registry trial [38]
Magee-Womens Hosp. [51]
St. Lukes Cancer Inst. [52]
Rush Univ. [53]
VCU multi-institutional [20]
MUSC [54]
WBH [43]
Multi-institutional [39]
WellStar Kennestone Hosp. [55]
UCSD/ABCS [33]
Device
MammoSite
MammoSite
MammoSite
MammoSite
MammoSite
MammoSite
MammoSite
MammoSite
Contura
Contura
SAVI
Number of
patients
43
1440
92
93
70
483
90
80
342
46
102
Median
follow-up
(months)
66
63
30
29
26
24
24
22
36
36
21
IBTR (%)
0 (at 5 years)
3.8 (at 5 years)
0
1.3 (at 3 years)
5.7
1.2
2.2
2.9
2.2 (at 3 years)
2
1
Cosmesis (%
excellent/good)
81.3
90.6
NR
NR
NR
91
90
88.2
88
97
NR
IBTR ipsilateral breast tumor recurrence, NR not reported, FDA Federal Drug Administration, ASBS American Society
of Breast Surgeons, VCU Virginia Commonwealth University, MUSC Medical University of South Carolina, WBH
William Beaumont Hospital, UCSD University of California, San Diego, ABCS Arizona Breast Cancer Specialists
1.2 %. The infection rate was 9 % overall but only

4.8 % when the implant was performed as a closed
procedure. Any telangiectasia was seen in 17 %
and significant telangiectasia in 5 % of patients.
Overall good-excellent cosmetic outcome was
91 %. The final results of the ASBS MammoSite
registry trial were recently presented consisting of
1440 patients and 1449 cases [38]. With a median
follow-up of 63 months, the actuarial IBTR at 5
years was 3.8 %. The rates of fat necrosis, infections, and symptomatic seroma were 2.5 %,
9.6 %, and 13.4 %, respectively, with few toxicity
events occurring beyond 2 years of follow-up.
The overall good-excellent cosmetic outcome was
91.3 % at 5 years and 90.6 % at 7 years.
Although the outcomes of the single-lumen
MammoSite catheter have been good, it became
clear that simplicity of the device limited any kind
of dosimetric modulation leading to suboptimal
outcomes in patient with close lumpectomy cavity
to skin distance. This led to the development of
multi-lumen devices as described above. The
Contura catheter is currently being evaluated in a
multi-institutional, phase IV trial. Initial results
were presented by Cuttino et al. consisting of 342
treated patients with median follow-up of 36 months
[39]. The local recurrence-free survival at 3 years
was 97.8 %. Treatment was well tolerated, with
implant-related infection observed in 8.5 %, fat
necrosis in 6.8 %, telangiectasia (grade 1) in 8.2 %,

and symptomatic seroma in 4.4 %. There was no
grade 24 telangiectasia or fibrosis observed.
Overall cosmetic outcome was good or excellent in
88 % of patients. Furthermore, patients treated at
high-volume centers appeared to have improved
outcomes with 3-year local recurrence-free survival
of 98.1 %, infection rate of 2.9 %, symptomatic
seroma rate of 1.9 %, and good-to-excellent cosmesis rate of 95 %.
Very early results with the SAVI catheter have
also been reported and are likewise encouraging
[33, 34]. Yashar et al. [34] reported on 102 patients
with a median follow-up of 21 months. Toxicity
was minimal with 1.9 % symptomatic seroma,
1.9 % grade 2 fibrosis, and 1.9 % asymptomatic fat
necrosis. In-breast failure was seen in only 1 % of
patients. More clinical experience and longer follow-up are needed to confirm these early results.
Toxicity Prevention
and Management
The success of an ICB implant should be evaluated not only on the success of prevention of disease recurrence but also with regard to
treatment-related toxicity and the ultimate cosmetic outcome. Adverse outcomes of the ICB
180
technique can broadly be grouped into two categories: insertion-related adverse events and
dosimetry/radiation-related toxicity.
Insertion-related complications include infection, hemorrhage, and implant failure from nonconformance of the applicator to the excision
cavity or balloon rupture/device failure. Prevention
of post-procedural infection is of particular importance as this has been shown to compromise the
ultimate cosmetic outcome [20]. Measures to minimize this risk should be taken. Insertion should be
performed with scrutiny to sterile technique.
Meticulous attention should be paid to wound care
during the time the applicator remains in place.
Prophylactic antibiotics have been used and may
be helpful but are not universally employed [20, 40,
41]. Analysis from the VCU experience has also
shown that a closed insertion approach as opposed
to intraoperative placement significantly reduced
the risk of infection by nearly half [20]. It appears
that by employing these simple measures, the
infection rate can be kept acceptably low even
when assessed among a broad base of users. In a
report of the ASBS MammoSite registry trial, the
device-related infection rate of 793 patients was
only 5.9 % [41].
Although we have learned much from the
early interstitial brachytherapy experience about
the dosimetric factors that lead to late toxicity,
ICB implants have distinctly different dosimetry
with distinctly different radiobiologic implication
with regard to normal tissue toxicity. Shah et al.
[42] reported a series of interstitial and
MammoSite implants and found significant differences in critical dosimetric parameters.
MammoSite implants are associated with significantly less irradiated tissue and smaller volume hotspots as compared to interstitial
brachytherapy. In contrast, the global uniformity
as reflected in the calculated dose homogeneity
index (DHI) is superior with an interstitial
implant. As a result, the lessons we learned from
interstitial brachytherapy with regard to late
tissue affects do not necessarily apply to
ICB. Clinical experience has taught us a host of
new factors that are important.
The initial single-lumen MammoSite device
had simple and predictable dosimetry with a near-
J.T. Hepel et al.
symmetric geometrical dose distribution. As such,

spacing between the applicator surface and the
normal tissue at risk is critical to determining normal tissue toxicity. This has been most clearly
shown with regard to skin toxicity. Benitez et al.
[37] evaluated the initial MammoSite FDA trial
showing a correlation with suboptimal results
when skin spacing was 0.7 cm. Chao et al. [43]
evaluated the William Beaumont Hospital experience consisting of 80 patients with a median follow-up of 22.1 months and found a similar
correlate of lower rates of good-excellent cosmetic outcome with skin spacing of <0.7 cm.
Cuttino et al. [20] in the VCU analysis also
showed the importance of skin spacing with a statistically significant correlation between skin
spacing of <0.6 cm and the rate of severe acute
skin reaction and late telangiectasia. Based on
these data, it is recommended for an applicator to
skin spacing of 0.7 cm which corresponds to a
maximum skin surface dose of <145 % of prescription. With the simple design of the initial
single-lumen MammoSite catheter, little can be
done for patients with inadequate skin spacing.
These patients are either not candidates for treatment or subject to increase risk of toxicity. The
new multi-lumen catheters were designed to allow
for 3D planning and customization of the dose
distribution. This has allowed for sparing of skin
dose in patients with close lumpectomy cavity to
skin distances. As a result, significantly lower
skin doses can be achieved and a more conservative maximum skin dose constraint is recommended, <100125 % of prescription. This more
conservative skin constraint may further reduce
the likelihood of late skin toxicity. In addition,
patients with skin spacing between 0.5 and 0.7 cm
are considered good candidates for treatment.
Other observed late toxicities include fat necrosis, persistent seroma, chest wall pain, and rib
fracture. Seroma rates of 2168 % have been
reported [4347], but only one third of these are
symptomatic [47]. The ASBS MammoSite registry trial found that seromas were reported more
often with intraoperative placement rather than
when employing the closed placement approach
(30 % vs. 19 %) and with the use of larger balloons
[20, 48]. Chest wall pain and rib fraction can be a
significant complication of the ICB technique and

are likely dependent on dose and irradiated volumes [49, 50]. With the initial MammoSite, a
maximum dose to the chest wall of <145 % of prescription was recommended. A more conservative
recommendation is used with the newer multicatheter devices of <125 % of prescription.
Conclusion
ICB represents a simplified brachytherapy

approach for APBI. Mature clinical experience has shown excellent outcomes in terms
of both prevention of tumor recurrence within
the breast as well as the overall cosmetic outcome. The newer multi-lumen catheter systems allow for flexibility in dose modulation
to allow for skin and chest wall sparing and
will likely improve outcomes in regard to toxicity endpoints. As with all APBI techniques,
the results of ongoing randomized trials will
definitively prove whether APBI is equivalent
to whole breast irradiation and will define the
optimal patient population for this approach.
Until mature data from these trials are available, the current clinical experience support
continued use of APBI delivered using ICB
for select patients.
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Breast Brachytherapy: Permanent

Breast Seed Implants How
and Why?
Jean-Philippe Pignol and Juanita Crook
Abstract
This chapter reports patient selection criteria, planning, technique, and

results of permanent breast seed implant. In a single 1 h procedure, this
technique uses stereotactic localization to permanently implant stranded
103
Pd seeds in and around the seroma cavity after lumpectomy for early
stage breast cancer. Five-year results for a cohort of 137 patients are excellent in terms of both local control and tolerance.
Introduction
Due to the widespread adoption of screening

mammography, the majority of breast cancers are
diagnosed at an early stage [1, 2]. These patients
have a good prognosis, and the 10 year risk of
dying of cancer is small [3]. The goals of therapy
are therefore to ensure local control and breast
preservation, to reduce long-term side effects,
and to minimize the burden of care. The current
standard of care is breast-conserving surgery,
which is most frequently a lumpectomy with
node sampling, followed by adjuvant whole
J.-P. Pignol, MD, PhD (*)
Radiation Oncology Department, Erasmus Medical
Center, Rotterdam, The Netherlands
J. Crook, MD, FRCPC
British Columbia, British Columbia Cancer Agency
Centre for the Southern Interior,
Kelowna, BC, Canada
breast irradiation (WBI) using small daily fractions of 5 days per week for 37 weeks [46].
Several reports have shown that for early stage
breast cancer, the majority of recurrences occur
in proximity to the surgical seroma [7]. Thus,
limiting radiation to the postsurgical cavity with
a margin may suffice to prevent local recurrencefree for carefully selected patients [8]. Irradiating
a smaller volume of breast allows treatment to be
delivered over a shorter period of time [9].
Accelerated partial breast irradiation (APBI) has
been tested since 1992 in multiple studies, including several multicenter randomized controlled
trials [1013]. The oldest and most frequently
used technique is brachytherapy, followed by 3D
conformal external beam radiotherapy (EBRT)
and intraoperative radiotherapy [14].
Historically, brachytherapy used low-doserate sources like iridium wires or iodine seeds
[15], but more recently multi-catheter and balloon high-dose-rate (HDR) brachytherapy have
become the techniques of choice [16]. A SEER

DOI 10.1007/978-3-319-26791-3_10
185
J.-P. Pignol and J. Crook
186
database analysis has revealed that HDR

brachytherapy patients may have a 1.5 %
increased risk of mastectomy which is very
unlikely to impact significantly on survival [17].
In 2006 the technique of permanent breast
seed implant (PBSI) for APBI was initiated at the
Sunnybrook Odette Cancer Centre [18]. This
approach was derived from permanent prostate
seed brachytherapy but required adaptation of
ultrasound image guidance and the use of a
fiducial needle to localize the target volume. To
date, patients have been treated in seven centers
in North America and enrolled in Phase I/II
studies for early stage invasive cancers, a Phase II
study for low-risk ductal carcinoma in situ
(DCIS), and a prospective multicenter registry
study. In Europe, one report described the use of
iodine seeds for a radiation boost after whole
breast radiotherapy [19].
This chapter describes patient selection,
treatment planning and the implantation
procedure, as well as the quality assurance
process, and outcomes of PBSI.
Indications
2.1
Rationale of PBSI Eligibility

Criteria
Initial APBI studies included some patients with

aggressive clinical or pathologic features such as
young age, nodal positivity, or close margins [10,
20]. In 2009 the American Society for Therapeutic
Radiation and Oncology (ASTRO) published a
consensus statement with relatively strict eligibility criteria for APBI [21]. Several other societies
followed with similar guidelines and recommendations [2224]. An appropriate patient for APBI
has a low risk of locoregional or distant relapse
and is node negative and hormone receptor positive, with a small infiltrating ductal carcinoma and
no lobular features, extensive carcinoma in situ, or
lymphovascular invasion. The Toronto experience
was initiated prior to the publication of these
guidelines and initially included patients as young
as 40 years of age and with more aggressive
pathologic features such as one to three positive

nodes and negative hormone receptors. Following
the publication of the guidelines, the protocols
were amended to be more restrictive, limiting the
minimum age to 50 and restricting eligible patients
to node negative with favorable pathology.
2.2
Currently Recommended
Clinical Criteria for PBSI
Eligible patients should be 50 years of age or

older and referred for adjuvant radiotherapy after
breast-conserving surgery. We do not recommend
PBSI for patients with a medical history of connective tissue disorder, poorly controlled or complicated diabetes, or those with post-lumpectomy
complications such as abscess or delayed wound
healing. At the first patient consultation, the technical feasibility of implantation is evaluated. With
the patient supine, there must be enough breast
tissue to implant or three planes of needles spaced
1 cm apart. In addition, seroma location in the lateral quadrants of the breast is preferable.
Implanting the upper inner quadrant tends to be
more challenging and can be associated with
more skin toxicity since the breast skin in this
region is in closer proximity to the chest wall,
especially when the patient is standing.
2.3
Pathologic Selection Criteria
PBSI should be limited to patients with unifocal

infiltrating ductal carcinoma of less than 3 cm in
diameter, resected with at least a 0.2 cm clear
margin or with negative re-excision margins. It is
unclear if non-luminal pathology, with negative
hormone receptors and overexpression of HER2,
or triple negative tumors are suitable for APBI
although some such patients were included in the
Canadian series. Also, although experience is limited, there is no strong rationale for excluding
DCIS. There is a general consensus to exclude
multifocal tumors, lobular pathology, lymphovascular infiltration (LVI), extensive carcinoma in
situ, and patients who are node positive. A 0.2 cm
Breast Brachytherapy: Permanent Breast Seed Implants How and Why?
negative margin for APBI may be questioned

given the recent data suggesting that no further
surgery is required before WBI provided there is
no tumor at the inked margin [25].
187
Technique
3.1
Planning
3.1.1
2.4
Planning Selection Criteria
The high dose of radiation delivered to the breast

with PBSI is not homogenous. As the dose
distribution cannot be optimized after the implant
is done, several precautions are taken to avoid
severe permanent side effects. Based on our
experience, we do not recommend implanting
volumes larger than 120 cc (corresponding to a
sphere of 6 cm in diameter). The skin dose should
be limited such that the maximum dose to an area
of 1 cm2 does not exceed 90 % of the prescribed
dose [26]. A breast ultrasound is performed either
during the first consultation or at the time of the
planning CT to ensure the fluid cavity constituting
the seroma is clearly visible and is not larger than
2.5 cm in the direction of the needle insertion.
Larger seromas are associated with greater seed
migration and possible accumulation of seeds at
the inferior aspect of the seroma. Finally the
shape of the implanted volume should permit the
placement of a minimum of two superimposed
planes of needles.
a
Computed Tomography (CT)

Simulation
Although the implant procedure is ultrasoundguided (US), the planning is CT based. The CT
simulation is performed with the patient lying
supine on a breast board, with one (or both) arm
abducted and supported above the head. The
position is identical to that for EBRT simulation
such that, in case the patient is found ineligible
for PBSI at time of dosimetry, the CT images can
be used for planning standard whole breast radiotherapy. The scar is identified using a thin metal
wire, and a lead bead is placed on the inferior
medial quadrant of the nipple (Fig. 1a, b). These
markers are used at the time of implantation to
help localize the seroma projection on the skin.
Wire to mark the breast skin folds is not required.
The CT images are acquired with the finest
spacing and thickness available to optimize the
resolution of re-sliced images in the planning system. At this stage it is important to ensure the
seroma is easily identifiable, of appropriate size,
and sufficiently far from the skin surface. This is
assessed by contouring the target volume on the
horizontal image sets before the re-slicing. The
b
Fig. 1 (a, b) The CT simulation is performed with the patient lying supine on a breast board, with wire and beads
placed on the surgical scar and the nipple
188
Fig. 2 The clinical target volume (CTV) is defined as the

surgical cavity, the microscopic extension of the tumor,
and a security margin. Practically this corresponds to the
seroma with an additional expansion of 1.5 cm
Fig. 3 For planning optimization, the needles are inserted

following a square or a triangular pattern, whichever fits
better to the PTV shape on the most central slice
clinical target volume (CTV) is defined as the

surgical cavity, the surrounding fibrosis, and suspected possible microscopic extension. Practically
this corresponds to the surgical cavity and its surrounding fibrosis, which are visible on CT as the
seroma, with an additional expansion of 1 cm
(Fig. 2). This expansion is limited to 0.5 cm below
the skin surface and to the surface of the fascia
pectoralis. The planning target volume (PTV)
incorporates an additional safety margin accounting for seed placement accuracy. In our experience this is an additional 0.5 cm expansion that is
also limited to 0.5 cm below the skin surface and
to the surface of the fascia pectoralis. Of note, the
seroma on US is always smaller than that seen on
CT as the US visualizes only the fluid-filled cavity
and not the surrounding fibrotic rim.
An important planning step is the selection of
the fiducial needle insertion point, angle, and
direction. The fiducial needle should pass
through the center of gravity (centroid) of the
CTV. Its trajectory goes from an entry point on
the posterolateral side of the breast and passes
through the breast with an angle tangential to the
chest wall to minimize the risk of lung perforation. The distance from the CTV centroid to the
chest wall can be adjusted at this time to enable
the first row of needles to be placed above the
fascia pectoralis.
If the case meets the technical requirements, the

CT images are then re-sliced in a plane perpendicular to the fiducial needle axis and evenly spaced by
0.5 cm. The new images are used for seed placement optimization in the planning process.
3.1.2 Planning
Seed placement optimization starts with localization of the template grid on the re-sliced images.
The grid is superimposed on the central image of
the PTV and the scale verified and adjusted if
necessary. This grid enables the loaded needles to
be spaced 1 cm apart. Needles are placed following a square or triangular pattern, whichever is a
best fit, to the PTV shape on the central slice
(Fig. 3). Unlike prostate implants where needles
are not placed centrally because of the urethra,
PBSI needles are evenly placed throughout the
PTV. This generates a hotter implant but also
prevents the occurrence of a cold spot in the
center of the CTV where the implantation pattern
may be stressed due to the natural motion of the
breast.
Once the positions are defined in the grid, the
needles are loaded with 103Pd seeds and spacers.
Seeds of 2.5 U of activity are initially selected and
are loaded into the needles in a staggered fashion
between adjacent needles to reduce hot spots. In
the peripheral needles, the seeds are spaced every
189
centimeter using alternating seeds and spacers.

Central needles should use two spacers between
each pair of seeds to minimize hot spots. The plan
can be optimized by adjusting the seed activity
within a range from 1.62.7 U and, when appropriate, by adding or removing seeds.
The preplanning optimization constraints are
as follows [26]:
When the plan is approved and the patient has

consented, a preanesthetic assessment is performed, which includes an ECG, chest X-ray, and
appropriate blood tests, depending on the patients
age and previous medical history. The implantation
date is scheduled, and the prescription stranded
seeds are then ordered.
The 90 % isodose line must not bulge through

the skin surface on more than 1 cm2.
The relative amount of PTV receiving at least
90 % of the prescribed dose (V90) is close to
100 %.
The volume of the PTV enclosed by the 100 %
isodose (V100) is between 95 and 100 %, and
the V200 is between 20 and 30 %.
3.2
PBSI Procedure
3.2.1
Patient Preparation
When using low energy photon sources, breast

density could have a major impact on the dose
distribution. For example, dose calculation on the
skin could be underestimated as much as 40 %
when the density of fat is not accounted for using
the TG43 protocol [27]. Since the skin is the
main critical structure for PBSI, we recommend
using a heterogeneity correction in planning.
Heterogeneity correction algorithms that are
suitable for low energy photon sources include
Monte Carlo simulation and the inhomogeneity
correction factor (ICF) [28, 29].
3.1.3
Dose Prescription
The biological equivalent dose to 50 Gy of

external radiotherapy using a low-dose-rate
source such as Pd 103 has been calculated from
two radiobiological models of tissue response.
The time, dose, and fractionation (TDF)
factor. The TDF of an EBRT dose of 50 Gy in
25 fractions over 5 weeks is 82. This is
equivalent to a PBSI dose of 90 Gy [30, 31].
The biological effective dose (BED) for an /
value of 3 Gy for late responding tissues is 76
for a 50 Gy EBRT in 25 fractions and 75 for
90 Gy PBSI [32, 33]. For / values of 10 Gy
corresponding to acute reaction, the BED for
EBRT is 52, but for PBSI it is 71, suggesting a
higher risk of acute reactions.
Patients are on liquid diet starting the evening

before the procedure and fasting from midnight.
They must stop any blood thinners prior to the
implant, 5 days for warfarin and 8 days for
ASA. On arriving in the brachytherapy suite,
patients are asked to change into a gown, and an
intravenous perfusion line is placed in the arm
contralateral to the implant. After a last anesthesia
evaluation, they are brought to the brachytherapy
suite and placed supine on a breast board on a
surgical table with the arms placed exactly as for
the planning CT. The positioning step is critical
as even minimal differences in the arm position
have an impact on the seroma location.
After anesthesia induction, the breast skin is
sterilized using chlorhexidine 0.5 % and sterile
drapes are placed. The projected PTV and the surgical cavity are outlined on the skin surface using
a sterile pen with the help of 3D reconstruction
printouts from the CT planning (Fig. 4). The surgical scar, tattoos from the time of CT simulation,
and the nipple marker are all used as references
for the drawing. The skin drawing is carefully
verified using ultrasound, ensuring that the surgical cavity is well centered within the drawing
boundaries, which can be modified if needed.
3.2.2 Anesthesia
The preferred anesthesia protocol is light sedation
that includes (i) Ketoprofen 200 mg PO BID for
48 h starting the day of implant and PRN for
15 days, (ii) Neuroleptic analgesia is induced with
IV propofol or a mix of fentanyl 100 g and
midazolam 0.3 mg/kg, (iii) Skin freezing using a
maximum of 30 ml of bupivacaine HCl 0.5 % is
performed on the area where the needles will be
190
Fig. 4 After anesthesia induction, the projected PTV and the surgical cavity are outlined on the skin surface using a
sterile pen with the help of 3D reconstruction printouts from the CT planning
inserted and the retroareolar complex using a longer

needle if seeds will be implanted in this area. The
skin area that has been anesthetized can be outlined
using a skin marker. This protocol was validated
prospectively and found effective on 31 patients
using a visual analog pain scale (VAS) [18].
3.2.3 Fiducial Needle Placement

The most critical part of the implantation procedure is the accurate placement of the fiducial
needle, which serves as a reference for seed
placement. The needle must accurately reach the
CTV centroid defined during planning, with the
same direction and angle as dictated by the plan,
and respecting the same distance to the skin and
the chest wall. Accounting for the bevel distance
and the bone wax, the tip of the needle is generally inserted 35 mm beyond the medial boundary of the drawing. US guidance for fiducial
needle insertion is essential. US is used to verify
the needle position relative to the seroma centroid projection marked on the skin and to verify
the distance from the needle to the skin and to
the fascia pectoralis. The needle direction and
depth of penetration are verified using the skin
projections and a ruler. The angle of penetration
is verified using an inclinometer. When the
Fig. 5 A template is attached to the fiducial needle using

the locking mechanism and immobilized using a medical
articulated arm. This apparatus enables precise placement
of the stranded seeds
fiducial needle position is deemed correct, a sterile template is attached using the locking mechanism and immobilized using a medical articulated arm (Fig. 5).
3.2.4
Alternate Approach to Fiducial

Needle Placement, the Kelowna
Technique
PBSI was introduced in British Columbia in 2012
according to the technique described supra.
Although the general principles are the same,
several modifications have been developed and

introduced to facilitate reproducibility of the technique, shorten the learning curve, and enhance the
confidence of a novice operator.
Just prior to the procedure, the patient is
brought to the CT suite where she is positioned
identically as for her prior CT simulation, on a
breast board, with a headrest and with the ipsilateral arm abducted and supported above her head.
This is accomplished by the attending radiation
technologists, as if she were being set up for her
first EBRT treatment. The nipple marker is then
placed, and lateral tattoo height from the table is
verified bilaterally to rule out any patient rotation. The translations from the nipple marker to
the projection of the CTV centroid on the skin
and to the fiducial entry point laterally are then
carried out using the wall lasers and adjusting the
couch. We find this much more reproducible than
measuring with a ruler along a curved skin surface. These reference points are marked on the
skin, and the seroma projection is drawn around
the CTV centroid and verified with US. No CT
imaging is required during this session.
The patient is then brought to the procedure
room, and light anesthesia is induced using a
laryngeal mask for airway protection. The same
team of radiation technologists repeats the
positioning and setup, verifying the lateral tattoos
and fiducial entry height using portable table
lasers. The articulated arm is then attached to the
OR table side bar. The articulated arm is not
sterile, but the template is, and the procedure
must be carried out under sterile protocol. Due to
logistic difficulties in trying to adjust the
articulated arm to get the sterile template
correctly positioned in a sterile field, we instituted
an initial nonsterile dummy run. We attach a
nonsterile template to the articulated arm and
maneuver it into position so that the blunt end of
a needle can be placed through the template at
exactly the right angle and hit the fiducial entry
point marked on the skin. We then lock the
articulated arm in this position, remove the
template, cover the articulated arm with a sterile
clear plastic scope bag, sterilize the skin, drape
the patient, and proceed with the sterile procedure.
The sterile template is then slipped into position
191
on the articulated arm, and the fiducial needle is

advanced through the template at the correct
angle to encounter the entry point on the skin.
The angle is verified with an inclinometer, and
the needle is advanced under US guidance to its
intended mid-seroma position. The rest of the
implant continues as described below.
3.2.5 Seed Insertion and Verication

The seed-bearing needles are inserted using US
guidance, starting with the deepest row closest to
the chest wall. For the first few rows, each needle
direction, distance to the fascia pectoralis, and parallelism to the fiducial needle are carefully verified
using US. When the needle positioning is deemed
correct within 0.10.2 cm of its planned position,
the seeds are released by stabilizing the trocar and
pulling the needle straight back along the trocar
until the hubs meet. The seeds can be released after
the insertion of each needle, or after the insertion of
multiple needles depending on the preference of
the operator. Inserting and positioning the needles
one row at a time before depositing the seeds help
to stabilize the breast and achieve parallelism.
When the implantation of all sources is done, the
skin is cleansed with chlorhexidine 0.5 % and gently rubbed to close the insertion holes, improve
adhesion of the strands, and prevent expulsion.
3.3
3.3.1
Post-implant Recovery, QA,

and Follow-Up
Radioprotection Measurements
and Patient Instruction
After the implant, the patient is brought to the
recovery room, and the exposure rate at one
meter is measured in multiple directions. It is
typically in the order of 2.5 mR/h and should be
less than 5 mR/h in order to release the patient
without additional radioprotection measures such
as a breast shield. A breast shield is a flexible,
circular flap of 0.06 cm-thick Xenoprene
(0.0175 cm lead equivalent) encased in thin soft
plastic [34]. When recommended, the breast
shield is placed inside the bra next to the
implanted area and can be worn for the first halflife of the seeds, or approximately 3 weeks.
192
Radioprotection measures reduce public exposure and more particularly exposure to the
patients partner and other family. Keller has estimated the effective dose received by the partner
over the course of treatment using a general equation. To keep this dose at an acceptable level, we
recommend the use of 103Pd instead of 125I as the
radioisotope of choice [35]. These estimations
were prospectively validated on a cohort of 36
patients whose partners were asked to wear radiation badges for the first month after the implant.
The average measured partner dose was 0.97 mSv
(range 0.065.1 mSv; SD = 1.0 mSv), which
remains within the acceptable dose range of
5 mSv annual exposure as recommended by the
National Council on Radiation Protection and
Measurements Commentary #11 [36] for nonradiation workers. Additional radiation safety recommendations are given to the patient at time of
discharge, including avoidance of close (within
1 m) and prolonged contact with pregnant women
or young children for 2 months (~3 half-lives) and
at least 6 months of strict pregnancy precautions.
3.3.2 Patients Follow-Up

After the implantation, patients can return to normal activity. They are asked to keep the dressing
dry and not to shower for 24 h. They are seen in
follow-up 1 or 2 months after the implant, at a
time when the acute skin reaction peaks. They
also undergo a repeat planning CT for quality
assurance purposes. Patients are followed clinically at 6 months then yearly and have annual
mammograms. In our experience there have not
been any negative issues for mammographic or
MRI surveillance. In the uncommon event that
targeted biopsies are recommended for calcifications in the implanted area, these can be undertaken without any special concerns.

Standards
often a challenging task to identify the seroma in

the implanted volume because of the artifact
created by the seeds and associated fibrosis. The
post-implant evaluation CTV should have the
same volume in cc as the pre-implant CTV.
Deformable image registration between pre- and
post-implant images facilitates and improves
accuracy of the QA process [37]. Dose-volume
histograms (DVH) are generated to calculate the
evaluation CTV V100 and V200.
In a review of 85 patients treated with PBSI,
Keller reported a mean evaluation CTV coverage
of 85.6 % 10.4 % SD for the V100 and
36.2 % 13.9 % SD for the V200 on CT scans
performed immediately after the implant. Over
time, the seeds seem to cluster together resulting
in apparently hotter implants. At 2 months the
mean V100 increased to 88.4 % 9.9 % SD and
the V200 to 48.3 % 16.6 % SD, but by that time
over 85 % of the radiation has already been
delivered.
Results
5.1
Clinical Outcomes
5.1.1
Local Recurrence-Free, DiseaseFree, and Overall Survival

Pooling together the patients from the first Phase
I/II study for early stage invasive ductal carcinoma, the Phase II study for ductal carcinoma in
situ, and the registry study, 88 % of the patients
are without evidence of disease after a median
follow-up of 58.6 months (unpublished data).
The actuarial local recurrence-free survival at
5 years is 98.8 % (SD 1.20 %), overall survival
97.4 % (SD 1.91 %), and the disease-free survival 96.4 % (SD 2.07 %). These outcomes are
similar to those expected for early stage breast
cancer treated with breast-conserving surgery
followed by whole breast EBRT.
5.1.2
A quality assurance postplan CT is performed

2 months after the implant. The seroma and its
expansion into an evaluation CTV are contoured
with the help of the pre-implant CT images. It is
Cosmetic Outcomes and Patient

Satisfaction
PBSI cosmetic outcomes and patient satisfaction
were reported for the patients accrued in the
Phase I/II study [38]. Independent assessment by
a trained clinical research assistant found that

96.9 % of the patients had excellent (83.1 %) or
good (13.8 %) cosmetic results at 3 years. The
vast majority of the patients (92.5 %) were
totally satisfied with the treatment and result
6 months after the implant.
5.2
PBSI Advantages
The precise role of APBI is still pending final

results of several multicenter randomized controlled trials in Europe, the USA, and Canada
[11]. There are also multiple techniques of partial
breast irradiation, each having advantages and
drawbacks. PBSI is a 1 h outpatient procedure,
performed under light sedation. The treatment
has minimal impact on the patients daily activities. These are clear advantages over other
brachytherapy or external beam APBI techniques. Only intraoperative radiotherapy (IORT)
delivered at the time of surgery can compete for
patient convenience. However, PBSI is offered
when the final pathology report is available,
ensuring appropriate patient selection and fully
informed consent, whereas IORT is delivered
before the final pathology and margin status are
known. Also, compared to other techniques,
PBSI delivers a very low dose to the heart and
other body organs [39]. This is potentially a significant benefit for patients who have little chance
of dying of their cancer and are receiving adjuvant radiotherapy because they chose a breastconserving approach.
5.3
PBSI Drawbacks
The strict clinical, pathological, and technical

selection criteria for PBSI render many motivated
patients ineligible. We found that following our
recommended pathology and age criteria reduced
the number of eligible patients to only 20 % of
those referred for adjuvant radiotherapy.
Eventually issues around the seroma size and
technical feasibility further reduce this number
by another 50 %. However, many of the ineligible
patients may be good candidates for other APBI
193
techniques such as balloon HDR brachytherapy

for patients with a large seroma, or interstitial
HDR brachytherapy. PBSI could hence be part of
a spectrum of therapeutic modalities where the
appropriate technique can be selected for a
specific clinic-pathological presentation.
Another drawback is that, although PBSI does
not result in significant postprocedural pain or
infection, it is still an invasive procedure which
may deter some patients. Also, some have
expressed concern about having material permanently implanted. To this end, current research on
bioabsorbable seeds based on alginate implants
of nanoparticles is justified. A final limitation is
that, like all brachytherapy procedures, specific
skills and training are essential. The implantation
must be perfect since there is no possibility to
correct a suboptimal implant. There is also a risk
of injury to the lung or heart if an inexperienced
radiation oncologist is implanting needles in the
breast, especially left-sided. Participation in a
training program is strongly advised, and experience in other US-guided interstitial implantation
procedures such as prostate brachytherapy is
clearly an advantage.
Complications
and Management
6.1
Acute Tolerance
6.1.1 Pain
During the implant procedure, 56 % of 31 patients
did not experience any pain and 25 % reported
minimal pain (VAS score, 0.52). For three
patients (10 %) the anesthesia protocol was
modified using only skin freezing without
sedation, but all experienced significant pain
during the procedure (VAS score, 6.58), so
neuroleptanalgesia was reintroduced and is
deemed essential to the anesthesia protocol.
In the first week after the implant, one third of
patients did not experience any pain, one third
reported minimal pain, and one third moderate to
significant pain (VAS score, 310). We observed
two peaks in pain, the first within 48 h and the
second at about 6 weeks. We interpret the first
194
pain flare to be related to hematoma formation

following needle insertion, and the second seems
to be due to the radiation dose to the skin. While
chronic pain after adjuvant WBI has been
reported in 43 % of patients in two series [40,
41], we rarely observed pain after 2 months. In
addition, no patient reported any increased
discomfort during follow-up mammogram.
6.1.2
Skin Side Effects
Acute side effects have been collected prospectively for 127 patients in three prospective trials in
Ontario, Canada. The most frequent acute toxicity
is skin erythema in the region of the implant which
occurred in 41.7 % of patients. Twenty percent of
patients noticed a lump due to edema. Moist desquamation was seen in 15.9 % of patients, but had
an impact on daily activities in only 5.6 %. In the
multicenter randomized trial of breast IMRT that
used the same impact scale, 31.2 % of patients
treated with breast IMRT and 47.8 % of patients
treated with a wedged technique experienced
moist desquamation [42]. One patient with complications of type I diabetes developed skin ulceration which took 4 months to heal.
6.2
Long-Term Tolerance
The most frequent delayed side effect is induration, occurring in the vicinity of the seroma in
23.2 % of patients at 2 years, plateauing at
39.2 % at 5 years. This induration is generally
asymptomatic and had no impact on the patents daily activities or treatment satisfaction
score. It could however sometimes impact on
the cosmetic outcome, creating a breast dimple
when the patient lifted her arm. This rate of
induration is higher than the 10 % fat necrosis
observed in the MammoSite registry trial
[43], but is similar to the rate of 39.5 % at
5 years rate reported by Ajkay using HDR
brachytherapy APBI [44]. These rates may
depend on the way fat necrosis is defined; however, it is likely that induration is a frequent
side effect of PBSI. We have observed telangiectasia in 22.4 % of the patients at 2 years, and
this rate remains stable at 24.3 % at 5 years.
The telangiectasia was mostly grade I, limited
Fig. 6 Telangiectasia are typically limited in area and

occurred more frequently when the patient had moist desquamation 6 weeks after the implant
in area, and occurred more frequently if there

was prior moist desquamation [40] (Fig. 6).
Interestingly, we observed that in four out of 11
patients the telangiectasia disappeared with
follow-up longer than 5 years.
Summary
PBSI is an effective means of delivering partial

breast irradiation for selected patients with
favorable breast cancer following breastconserving surgery and sentinel node evaluation. It compares favorably to alternate methods
of partial breast radiation in terms of patient
convenience, cosmesis, and limitation of dose to
adjacent organs.
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Breast Brachytherapy: Brachytherapy

in the Management of Ipsilateral
Breast Tumor Recurrence
Mark Trombetta, Thomas B. Julian,
and Jean-Michel Hannoun-Levi
Abstract
In this chapter, we present an alternative management of ipsilateral breast

tumor recurrence following conservation therapy for early breast cancer.
We will present the evidence to date and hope to establish this alternative
approach as a plausible option for women affected by in-breast recurrence,
but desirous of breast preservation. We discuss this option presenting the
established standard of care and the alternatives, as well as the specific
concerns related to retreatment.
Introduction
According to the World Health Organization,

International Agency for Research on Cancer
(IARC), more than 1.7 million women were
diagnosed with breast cancer worldwide in 2012
M. Trombetta, MD (*)
Professor, Division of Radiation Oncology,
Allegheny Health Network Cancer Institute, Drexel
University College of Medicine, 320 East North
Avenue, Pittsburgh, PA, USA
T.B. Julian, MD
Department of Surgery, Allegheny General Hospital,
Temple University School of Medicine,
Drexel University College of Medicine,
Allegheny Health Network, Pittsburgh, PA, USA
J.-M. Hannoun-Levi, MD, PhD
Radiation Therapy Department, Antoine Lacassagne
Cancer Center, Nice, France
(the most recent data reported to date), which

accounts for approximately 12 % of all cancers
[1]. Of that number, up to 70 % of patients will
have selected breast conservation therapy [2],
depending on global and local practice patterns.
Unfortunately, it has now been replaced by less
curable lung cancer as the most common malignancy in women. Additionally, the IARC noted
that the breast cancer incidence had increased by
more than 20 % since the 2008 estimates with an
overall 14 % increase in mortality worldwide.
Coincidently, the mortality rate in the developed
countries (the United States, Europe, Canada,
etc.) has fallen significantly [3]; hence, people
affected by breast cancer in much of the world
are living longer, adding to the potential for an
increase in the rate of ipsilateral breast tumor
recurrence (IBTR). The risk of breast cancer
recurrence for a given subject depends on a variety of factors, including patient age, inherited
susceptibility, tumor characteristics, type of treatment for original tumor (e.g., surgery and/or radi-

DOI 10.1007/978-3-319-26791-3_11
197
M. Trombetta et al.
198
ation therapy), and other lifestyle factors such as

obesity and alcohol consumption. Currently, the
local recurrence rates after completion of adjuvant therapy are still approximately 220 %
(range 236 %) after a minimum 10-year followup [4, 5] depending on clinical and biologic factors, with a generally noted trend of increasing
recurrence rates inversely proportional to age at
diagnosis. When enhanced with hormonal
manipulation, the recurrence rates drop to
220 % in lower risk and hormonally sensitive
patients [46].
Paradigm Shift: The Era

of Breast Conservation
in Breast Cancer
Management
2.1
Role of Retreatment
90 % [9, 10]. While the rate of local control is

acceptable, these patients are often left with cosmetically and functionally suboptimal results [11,
12]. A number of studies have shown that mastectomy is displeasing and devastating to many
women, especially when the acute posttherapeutic phase has past and patients have time
to reflect [12, 13], but real functional problems
can develop related to physical asymmetry and
the resultant degenerative structural spinal disorders such as kyphosis and scoliosis. The interest
in retreatment in the setting of IBTR is growing as
evidenced by the fact that the Radiation Therapy
Oncology Group (RTOG) has recently completed
a retreatment protocol using hyperfractionated
external beam radiotherapy [14].
2.2
The concept of breast conservative treatment

(BCT) as an alternative to the traditional Halsted
radical mastectomy (and the subsequent modification of such) began to take shape in the 1970s.
Seminal efforts by Veronesi et al. at the European
Institute of Oncology (EIO) based in Milan, Italy,
were nearly concurrent with the efforts of Fisher
et al. at the National Surgical Breast and Bowel
Project (NSABP) based in Pittsburgh,
Pennsylvania, USA. From the beginning, the
Italian and American teams faced difficult criticism in postulating that less than radical surgery
was necessary to control or cure breast cancer.
Halstedian surgeries had been the established
standard of care for nearly 80 years. By the mid1980s, initial reports from both groups demonstrated equivalence, and in 2002 both groups
reported their 20-year follow-up which established BCT as the new standard local treatment
for appropriately selected patients [7, 8].
The primary goal of such therapy is eradication of disease, but important secondary goals are
cosmetic and functional preservation. For IBTR,
the international standard of care for local recurrence following breast conservation therapy has
been salvage mastectomy, which is physically
well tolerated by most women and has demonstrated salvage local control rates of greater than
Psychological Issues
and Breast Conservation
The issue of mastectomy and the subsequent

emotional and physical distress associated with
this therapy have been well described. Ganz et al.
[11] have demonstrated a clear cause-effect
relationship between mastectomies and clothing
difficulties as well as body self-image.
In the study by Rowland et al. [12], patients who
underwent lumpectomy, modified radical mastectomy (MRM), and modified radical mastectomy
with subsequent reconstruction surgery were evaluated. The post-analysis findings revealed that
women who had undergone MRM with reconstruction had the highest incidence of negative
impact upon their sex lives (45.4 % versus 29.8 %
of women undergoing lumpectomy). Maunsell
et al. [13] further subdivided groups of women noting that women under age 40 who had conservation
surgery were significantly less negatively affected
than those who had undergone MRM.
2.3
Indications
Patients with a significant surgical defect or

limited remaining breast tissue should generally
not be considered for conservation from a
cosmetic standpoint, but even in this situation, a
face-to-face discussion should be proposed to the
Breast Brachytherapy: Brachytherapy in the Management of Ipsilateral Breast Tumor Recurrence
patient who would be willing to accept a

suboptimal cosmetic outcome as a consequence
of a second conservative treatment. In these
patients, mastectomy, the accepted standard of
care must be discussed. We also recommend
consideration of repeat conservation in patients
with favorable recurrent tumor characteristics
only according to the breast size, maximum
tumor size between 2.0 and 3.0 cm, negative final
margins of resection, no clinically apparent
lymphadenopathy, and generally no evidence of
metastatic disease. In rare cases of bone-only
metastatic disease or when a suspected long-term
survival is possible, or even in the situation of
patient preference, retreatment lumpectomy and
radiotherapy could be reasonable. Finally, the
therapeutic
endeavor
must
demonstrate
equivalence in terms of overall life expectancy.
While salvage mastectomy following IBTR
has long been the accepted standard, repeat breast
preservation is possible in those women who:
(a) Are desirous of breast preservation
(b) Have recurrent disease limited to a single site
of the breast
(c) Demonstrate no evidence for residual disease
at the time of postoperative imaging
(d) Have enough projected residual breast tissue
to warrant breast preservation
(e) Are well informed about the risks versus
benefits of the procedure and the alternatives
including the possibility of recurrence and
resultant mastectomy with potentially
additional healing concerns
Treatment Options for IBTR
3.1
Mastectomy Following IBTR
it is important to notice that the vast majority of

those retrospective studies reported contain results
from patients who presented with locally advanced
stages at the time of IBTR.
In the study by Huang et al., nearly all patients
recurred with similar characteristics related to
invasiveness [17]. That is, nearly all of those
patients initially presenting with invasive lesions
re-presented with invasive lesions, whereas of
those with an IBTR following conservative treatment for Ductal Carcinoma in Situ (DCIS)
recurred with DCIS. The findings at the Allegheny
General Hospital in Pittsburgh, PA (USA), differed in that there was less correlation between
the original and recurrent pathology [23].
Many authors have described the synchronous
presentation of IBTR with distant metastatic disease which may occur in 515 % of patients [18, 21,
22]. Management of these patients primarily concerns the management of the systemic failure.
Therefore, these patients should not be considered
for repeat breast conservation. A 5-year survival
rate of only 37 % was identified in patients who
underwent salvage mastectomy alone [20]. One
patient in our original cohort of interstitial patients
did have metastatic disease at the time of evaluation
for repeat conservation therapy; however, she was
treated in the era of high-dose chemotherapy and
bone marrow salvage [23, 24], which was thought
to be curative in such patients at the time. She was 2
years disease-free from her transplant when she
developed an IBTR. She succumbed to disease
approximately 2 years following retreatment, free
of locally recurrent disease. In case of synchronous
IBTR and metastatic disease, a second conservative
treatment must be carefully discussed, taking into
account the patient point of view.
3.2
We have stated that mastectomy has been considered the standard of care for IBTR with local control rates of 236 % being reported [1522].
However, when studies of only large numbers of
patients (>100) are considered, local failure rates
dramatically decline to less than 10 % overall [15,
1719]. These excellent local control rates with
mastectomy alone established salvage mastectomy as the standard of care for IBTR. Furthermore,
199
Observation Only
Following Repeat
Lumpectomy for IBTR
Repeat lumpectomy without adjuvant local

therapy following local recurrence has been
reported by a number of authors. Multiple authors
report local recurrence rates following IBTR
treated by re-excision of 1935 % compared to
24 % in patients treated with salvage mastectomy
M. Trombetta et al.
200
[15, 22], with one group noting no difference in

disease-free survival [15]. Komoike et al. [16]
reviewed patients who developed IBTR in a
sample of 979 patients evaluated. Fifty-three
patients did not receive initial postoperative
irradiation in the cohort. Of the entire group, 47
developed IBTR including 15 with positive
margins at lumpectomy. With salvage mastectomy
and repeat lumpectomy used in this group, the
overall survival was in excess of 90 % [16]. Some
authors have asked whether surgery alone even in
de novo cases is enough. In general, the consensus
for invasive cancers is that all patients should
have follow-up radiotherapy. Since we know that
adjuvant radiotherapy to the primary decreases
significantly the rate of local recurrence (even if
there is no change in terms of OS); it is probably
hazardous to claim that it is possible to avoid
breast re-irradiation in case of IBTR following
conservation surgery [2527].
For DCIS, the decision is less definitive. A
number of authors and groups have proposed
potential subsets of patients who may not require
postoperative radiotherapy if they are
appropriately counseled about the low absolute
risk reduction of both local recurrence and overall
survival in favorable subgroups [2831], but to
date, no study has demonstrated a clear subgroup
in which radiotherapy does not reduce local
recurrence. National Surgical Adjuvant Breast
and Bowel Project (NSABP) and others have
demonstrated the need for radiotherapy in all
subsets of women [32, 33]. Silverstein et al. [30]
demonstrated that for de novo DCIS patients
undergoing local excision with negative final
margins of resection, no further local therapy was
required. However, the extensive pathologic
assessment in this study is beyond that routinely
practiced and may be impractical in most clinical
settings. Also, the study required margins of
resection of at least 2.0 cm to demonstrate a relative low risk of IBTR. As the volume of tissue
excised increases exponentially with increasing
linear resection margins [volume of a
sphere = (4/3) r3], this marginal requirement
may lead to suboptimal cosmesis. In patients who
are undergoing repeat resection, even small volumetric increases may result in poor cosmetic out-
comes due to the extent of tissue defect from

multiple surgeries. While the re-excision data
noted above are not robust enough to give definitive correlation with the later referenced de novo
data, local failure rates from re-excision seem to
mirror local failure rates in de novo cases.
Considering these data, it is likely that repeat surgical excision alone may result in suboptimal
outcome.
3.3
Comparative Studies
Between Salvage Radical
Mastectomy and Second
Breast-Conserving Surgery
Alone
Four retrospective studies compared clinical

outcomes obtained after salvage mastectomy or
second BCT consisting of re-excision without
re-irradiation [8, 13, 16, 23]. Kurtz et al. [22]
retrospectively analyzed the clinical outcome of
118 patients treated either with salvage
mastectomy (66 patients) or repeat BCT (52
patients). With a median follow-up of 84 months,
the rate of second local recurrence was 12.1 %
and 23 % for salvage mastectomy and repeat
BCT, respectively. Salvadori et al. [15] retrospectively analyzed the clinical outcome of 191
patients who presented an IBTR after BCT for
the primary. Among those patients, 134 underwent salvage mastectomy, while 57 were treated
with re-excision alone. At a median follow-up of
73 months, the authors noticed a higher risk of
second local recurrence in case of repeat BCT
(19 % vs. 4 %), while the 5-year Overall Survival
(OS) was 70 % and 85 % for mastectomy and reexcision, respectively (metastatic rates were
47 % and 20 % for salvage mastectomy and reexcision alone, respectively), and no significant
difference was observed between the two salvage
procedure in terms of Disease Free Survival
(DFS). Alpert et al. [63] retrospectively analyzed
the clinical outcome of 146 patients who presented with an IBTR after BCT for the primary.
Among those patients, 116 underwent salvage
mastectomy, while 30 were treated with salvage
breast-conserving surgery. The rates of second
local recurrence were 6.9 % and 6.7 % after mastectomy and salvage breast-conserving surgery,
respectively, with the second IBTR tumor size
significantly larger in the mastectomy group.
There was no difference in terms of distant
metastases between the mastectomy cohort
(31.8 %) and the breast-conserving surgery
cohort (23.9 %). Ten-year OS was not significantly different between mastectomy (65.7 %)
and salvage breast-conserving surgery (58.0 %).
Chen et al. [64] retrospectively analyzed the clinical outcomes of 747 patients who presented with
an IBTR after a BCT. Among those patients, 568
underwent salvage mastectomy and 179 were
treated with a salvage breast-conserving surgery.
Five percent of patients with mastectomy and
21 % of patients with salvage breast-conserving
surgery received postoperative irradiation.
Patients in the mastectomy group were younger
and had larger, high-grade, and hormone receptor-negative tumors. The authors observed a significantly better 5-year OS after salvage
mastectomy compared to salvage breast-conserving surgery (78 % vs. 67 %, p = 0.003). This study
is of interest due to the high number of patients.
However, several data points were not specified
(median follow-up, specific details regarding reirradiation dose and technique applied), making
the interpretation of this study debatable.
3.4
External Beam Radiotherapy

Following Repeat
Lumpectomy for IBTR
Very little has been published regarding the use

of external irradiation in the management of
IBTR following conservation surgery and postoperative irradiation. Recht et al. [20] reported on
a single case of IBTR treated with wide excision
and postoperative external irradiation that was
disease-free 72 months postprocedure. Mullen
et al. [36] published an initial report describing a
series of patients retreated following IBTR, and
Deutsch [37] later expanded this to 39 patients
who developed IBTR after breast conservation
therapy (BCT). In this study, all patients initially
received 45005040 cGy at 180200 cGy/frac-
201
tion following breast conservation surgery. The

initial pathology was invasive ductal carcinoma
in 31 and DCIS in 8 patients. When the recurrences were analyzed, 26 of the patients who
originally had invasive cancer recurred with invasive cancer, whereas the eight patients who presented with DCIS recurred with DCIS [although
two specimens demonstrated microinvasion].
Five patients had positive margins of resection at
the time of re-irradiation. Re-irradiation consisted of 5000 cGy (200 cGy/fx) of photon or
electron external beam therapy in all but a single
patient who did not complete therapy. Eight of 39
patients (20.5 %) developed a second IBTR with
three of these occurring in the same quadrant of
the breast. Though not scored according to the
NSABP criteria, cosmetic results roughly corresponded to NSABP category 1 or 2 for 15
patients, category 3 for 15 patients, and category
4 cosmesis for 9 patients. Each patient reported
satisfaction with the cosmetic effect compared to
mastectomy.
3.5
Interstitial Brachytherapy
Following Repeat
Lumpectomy for IBTR
Accelerated Partial Breast Irradiation (APBI) for

in-breast recurrence following whole breast irradiation is denoted as APBrI. Currently, for APBI,
different irradiation techniques are available with
intra (electrons IORT or 50 Kv X photons)- or
postoperative radiation therapy (brachytherapy
or external beam RT), while brachytherapy
techniques are based on preoperative (balloon,
multicatheter interstitial) or postoperative (multicatheter interstitial) techniques. In case of APBrI,
all technical options are described in the literature (except IORT with e-), while interstitial
brachytherapy remains one of the most popular
methods. Interstitial brachytherapy can be performed intra- or postoperatively and can use low[24, 3840], pulsed [41] or high-dose rate (HDR)
[4244] radiation. Due to radioprotection and
dose optimization considerations, HDR interstitial brachytherapy is currently considered as a
standard of care. Furthermore, this technique
202
allows for an outpatient procedure, leading to a

more comfortable and acceptable treatment for
the patient.
For APBI as well as for APBrI, the delineation
of the target volume remains a critical point.
Whatever the APBrI technique used, clips within
the tumor bed represent an important point for
this delineation. Recently, the Breast Cancer
Working Group of GEC-ESTRO proposed some
recommendations to define and delineate the
target in case of APBI using multicatheter
interstitial brachytherapy [34].
Briefly, five different steps are described:
1. Detailed knowledge about the primary
surgical procedure (particularly about type of
surgery, use/number and location of surgical
clips, tumor bed-related position of the skin
scar), details of the surgical pathology
including size of resection margins in six
directions, as well as the details of the
preoperative imaging (mammography and/or
MRI and/or ultrasound) is obligatory.
2. Identification of the tumor localization before
breast-conserving surgery inside the breast
and translation of this information into a
current CT imaging data set.
3. Calculation of the size of safety margins
needed to cover CTV in all six directions.
4. Definition of the target clinical target volume
(CTV)/planning target volume (PTV).
5. Delineation of the target CTV/PTV
according to defined rules.
For interstitial brachytherapy, the rules of
implant must follow the Paris system
recommendations [35]. It is important to implant
(if possible) at least two planes with, in this case,
a minimum number of 1012 catheters. For
Pulsed Dose Rate (APBI) or HDR brachytherapy,
planification should be done based on a 3-D
imaging approach (utilizing a CT scan). Dosevolume adaptation can be performed automatically with dedicated software using graphical
optimization. Dose-volume histogram (DVH)
analysis should confirm that the prescribed dose
covers 90 % of the PTV, with a dose nonunifor-
M. Trombetta et al.
mity ratio (DNR): V150/V100 0.35 (preferably 0.30). The V150 is defined as the volume
receiving 150 % of dose, with the V100 similarly
identified for 100 % of dose. The maximum surface skin dose should be 70 % of prescribed. A
confluence of two V200 % isodoses or a V200 %
isodose diameter >10 mm must be avoided.
Regarding the prescribed dose for HDR
brachytherapy, the protocols used for APBI were
empirically reported for APBrI: 34 Gy (3.4 Gy/
fraction over 5 consecutive days) or 32 Gy (4 Gy/
fraction over 4 consecutive days), while for PDR
brachytherapy, a total dose of 4650 Gy can be
delivered (0.500.80 Gy/h, 1 pulse/h, 24 h/day).
In case of re-irradiation for a second breast
conservation therapy (BCT), interstitial brachytherapy was the most commonly applied technique using either low-dose rate (LDR) [24,
3840], pulsed (PDR) [41] or high-dose rate
(HDR) [42, 43]. In case of interstitial
brachytherapy, whatever the dose rate used,
vectors (needles or plastic tubes) were implanted
intra- or postoperatively. The mean delivered
dose was approximately 46 Gy (range 3050 Gy)
and 32 Gy (range 3034 Gy) with LDR or HDR,
respectively. The second local recurrence rate
was 10 % (range 026 %). The 5-year DFS rate
was 60 % (range 3185 %), while the 5-year OS
rate was 75 % (range 5089 %). The grade 34
complication rate was 8 % (range 311 %), and
cosmetic results were reported as excellent/good
in 70 % (range 53100 %). Maulard et al. [40]
have retrospectively compared IBTR treated by
salvage brachytherapy alone (LDR 6070 Gy)
with second BCT with postoperative
brachytherapy (LDR 30 Gy). Tumors treated
with salvage brachytherapy alone were
statistically larger. The authors reported a second
local recurrence rate of 26 % and 17 % after
surgery plus brachytherapy and brachytherapy
alone, respectively. Hannoun-Levi et al. [39]
have retrospectively analyzed a series of 69
patients who underwent a second BCT for IBTR
using LDR brachytherapy. Two groups of patients
were compared regarding the delivered dose (30
vs. 46 Gy) and the number of plans used (1 vs. 2).
The authors showed that the second local
recurrence rate was lower in case of higher

delivered dose and larger irradiated volume.
Using PDR brachytherapy combined with a
repeat lumpectomy for IBTR, Kauer-Dorner
et al. [41] reported an actuarial 5-year second
local control rate of 93 % with a mean follow-up
of 57 months (two patients experienced a second
local relapse). Five-year DFS and OS were 77 %
and 87 %, respectively. Grade 34 late side
effects were 7 %, while cosmetic outcome was
excellent to fair in 76 %. Regarding quality of
life, the authors reported that mean scores of
scales and items of QLQ-BR23 were comparable
to primary breast-conserving therapy. Guix et al.
[42] have retrospectively analyzed a series of
patients who were treated with second BCT and
interstitial high-dose rate brachytherapy. With a
median follow-up of 89 months which
corresponds to the longest follow-up in this
specific field, the authors reported 10-year DFS
and OS rates of 64 % and 97 %, respectively. In
this series, no grade 34 complications were
observed. More recently, the GEC-ESTRO Breast
Cancer Working Group presented the results of
an international multicentric retrospective study
of 217 patients with IBTR who underwent a
second BCT for IBTR combining salvage
lumpectomy plus interstitial brachytherapy [44].
The authors reported an actuarial 5- and 10-year
second local recurrence rate of 5.6 % and 7.2 %,
respectively, while the actuarial 5- and 10-year
distant metastasis rates were 9.6 % and 19.1 %,
respectively. Actuarial 5- and 10-year OS rates
were 88.7 % and 76.4 %, respectively.
3.6
Intracavitary Brachytherapy
Balloon brachytherapy gained wide acceptance

in the USA and Europe following its introduction
in 2002. Since that time, hundreds of thousands
of procedures have been performed. The longest
trial to date was the MammoSite (Hologic Inc.,
Bedford, MA) registry trial which was overseen
by the American Society of Breast Surgeons. In
1449 patients with a median follow-up of 60
months, the IBTR rate was only 3.6 % which
compared favorably with standard whole breast
203
radiotherapy [45]. In this study, elsewhere failures (tumors recurring outside of the original
tumor bed and thought to be new tumors) (EF)
were significantly higher (2.6 %) than true
recurrences (tumor recurring in and around the
original tumor bed) (TR) (1.1 %). Because TR
results in lower survival rates [46], retreatment
localized radiotherapy requires additional discussion with patients. Soon after approval, we published our original experience using the
MammoSite balloon catheter in IBTR retreatment [47]. Additional devices utilizing a strut
construction are available and can be substituted.
We prefer multilumen balloons due to ease of
use, adjustability of size following implantation,
and ease of explantation (Table 1).
Interstitial brachytherapy has enjoyed wide
usage and acceptance since it was one of the
seminal methods of radiotherapy. However, the
significant learning curve and experience level
needed to provide excellent therapy is often a
dissuading influence for clinicians. Sadly, many
training programs have fallen away from interstitial therapy as patients look for more convenience and clinicians look for ease of use and
work flow advantages. The relatively small
number of experts in this method and the small
number of training sites that actively use
Table 1 Comparison of interstitial and intracavitary

brachytherapy
Interstitial
More experience overall worldwide
Most mature data
Better and more uniform dose distribution
Can be LDR or HDR
Requires significantly more technical skill
Does not require surgical assistance in many centers
Intracavitary
Ease of use
Improved workflow
Significantly less homogeneity
Requires surgical collaboration
May be better accepted by surgical community
Less trauma to the skin
Less wound risk for infection
Easier for patient compliance
M. Trombetta et al.
204
interstitial brachytherapy make for a dearth of

interstitial brachytherapists in many countries.
Intracavitary brachytherapy (ICB), whether by
balloon device or strut, has filled this void in
many professional communities. Originally
driven by breast surgeons (and in some institutions, interventional radiologists), the devices
have gained wide acceptance in a multidisciplinary setting. From a technical aspect, the
single catheter devices are much easier to use
than their multicatheter counterparts. For the
surgeons, it is a simple additional procedure.
For the brachytherapist, the ease of use following implantation adds to workflow efficiencies
and does not require radiotherapist operative
time. From a practical standpoint, the theoretical risk of infection is lessened with a single
entrance wound as compared with multiple
entrance and exit wounds with the interstitial
approach. Although infection rates vary across
many small sample sizes in the studies to date,
the infection rate with balloon catheters tends to
be reported at less than 5 %. We have noted an
infection rate of 2 %. The overall trauma to the
breast considering the lesser number of puncture sites is also reduced with potential improved
overall cosmesis. Despite the large diameter difference between the single catheter, multilumen
devices, and the smaller 17 or 18 gauge diameter of the interstitial approach, overall patient
acceptance is quite good and the resultant incisional scar is many times imperceptible, especially considering the ominous appearance of
the wound with the device in place.
Selection of the correct patient for strut or
balloon brachytherapy in general and retreatment brachytherapy specifically is critical for
good outcomes and patient safety. Generally we
follow the consensus guidelines first authored
by the American Society for Radiation Oncology
(ASTRO) [48] and later updated and adopted by
the American Brachytherapy Society (ABS)
[49] (Table 2), although there is significant clinical latitude between investigators on what clinical features would make a patient fit for
acceptable guidelines. Clinicians should use
reasonable standards of care when selecting
such patients.
Table 2 ABS guidelines for APBI

Age
Size
Histology
Estrogen receptor status
Surgical margins
Lymphovascular space
invasion
Nodal status
>50 years
<3.0 cm
All invasive and DCIS
Positive/negative
Negative
Not present
Negative
For retreatment, we do not limit prior subtypes or type

of cancer
For retreatment we have treated patients with 13 nodes
positive at recent axillary sampling
3.7
Intracavitary Brachytherapy
Technique
Following a complete history and physical examination, current discussion of the standard of care
(including mastectomy), and multidisciplinary
consultation, patients who are accepting of
retreatment with balloon brachytherapy are admitted either to a surgical or radiologic suite, or in
some cases a clinical office. Generally, ultrasound
is used to guide the placement of the device, and
we perform a pre-procedure sonogram to document the existence of a seroma cavity and verify
appropriate cavity-to-skin distance (usual
accepted minimum 0.3 cm). The pre-procedure
sonogram also is helpful in determining balloon
diameter and shape (spherical or ellipsoid) or strut
size. Under sedation and local anesthetic, or in
some cases, local anesthetic alone, a 1.52.0 cm
incision is made in the lateral or inferior breast
margin. Other pathways can be utilized, but we
have found that, when possible, these entrance
sites are most comfortable for the patients. We do
not use the lumpectomy surgical incision entry
technique as this may worsen cosmesis in a physically evident section of the breast. The entrance
trocar is passed through the incision using constant guidance by ultrasound into the seroma cavity. If the balloon is placed following establishment
of complete excision and obtainment of negative
margins, the balloon catheter is placed and saline
is infused into the balloon (or the strut is expanded
and fixed). Five cc of a standard opacification
solution is infused as part of the balloon fill. We
have found that higher amounts of contrast

obscure the balloon surface margin and sometimes surrounding structures. We use only multilumen catheters for therapy to provide maximum
flexibility of dose distribution. If a catheter is
placed at the time of definitive surgery, an interim
cavity device should be used as a place holder
until the final pathology can be confirmed as suitable for implant. Broad spectrum antibiotics are
initiated intraoperatively and continued until day
2 post-explantation. Analgesia is generally not
necessary or acetaminophen is recommended.
Following verification of pathology, a noncontrast CT planning scan should be performed
with the device in place to allow for dosimetric
calculations. We use 0.3 cm slice thickness and
limit the scan to encompass organs at risk and
minimize dose to the nonessential tissues. We
limit the scan as well to the area of interest only
to eliminate the inevitable potential nonsignificant
findings that are sometimes seen on unenhanced
scans or with suboptimal diagnostic techniques
and may cause undue concern. Planning criteria
are those used standardly for the devices and
memorialized in NSABP protocol B-39 (RTOG
0413). For patients with brittle skin or other
concerns, dose reduction has been utilized
occasionally, both in dose per fraction and total
dose. Caution must be utilized in reduced dose
treatments as there has been a trend toward lesser
local control rates with reduced total dose in
LDR applications [39, 50].
The daily treatment with balloon catheters
requires balloon integrity verification and catheter
lumen integrity evaluation before each individual
fraction is delivered, although some clinicians perform the verification procedures once daily. We
recommend ultrasound verification as opposed to
serial CT verification to minimize radiation dose
to uninvolved organs. If ultrasound is not available, we recommend limited CT scanning in a
manner similar to that used for initial dosimetric
data capture. For diminished fluid volume findings
in the balloon as evidenced by diameter variations
of greater than 0.2 cm between fractions, saline
can be added to the balloon to restore the initial
diameter. Rotational variances of up to 15 in
either the clockwise or counterclockwise direction
205
have shown to cause minimal and insignificant

dosimetric variances [51], but care should be taken
to check alignment and adjust the balloon rotation
before each fraction if the variance is greater than
these parameters. With severe and frequent variations in diameter, the balloon should be replaced.
We recommend that catheter covers be used
between treatment to prevent debris from entering
the catheter lumens. Upon completion of therapy,
the balloon is removed first by painting a germicidal solution on the skin around the catheter. The
balloon is then deflated and then gently twisted
360 to loosen tissue adhesions. A constant firm
but careful pull on the device usually frees it with
minimal discomfort. The excess seroma fluid is
then gently expressed following explantation, and
the wound is covered with a small bandage. When
the wound heals over, the patient is allowed to
shower or bathe. Until that point, we recommend
sponge bathing. The patient is instructed in postoperative wound care and expectations and discharged from the brachytherapy suite.
Dose distribution comparison example of single versus multilumen applications (0.8 cm skin
to balloon surface distance) (Figs. 1 and 2).
3.7.1
Results
Twenty-two patients have been retreated with

intracavitary brachytherapy at Allegheny General
Hospital as of the time of this writing. The mean
time to IBTR was 141 months (range
26341 months). At a mean follow-up of
42.1 months (range 1576 months), only two
patients developed a local recurrence both successfully locally treated with salvage mastectomy.
One patient recurred with inflammatory carcinoma within 1 year of treatment, raising suspicion
of occult aggressive disease underlying what was
originally thought to be a 2.0 cm moderately differentiated IDC with clearly negative (1.0 cm)
margins. She expired 1 year later from extensive
metastatic disease. No patient developed any
acute reaction greater than grade II erythema as
scored by the Common Terminology Criteria for
Adverse Events scale (CTCAE v4.03) [52].
Cosmesis as graded by the NSABP/Harvard Scale
[53] (Table 3) was grade I in eleven patients,
grade II in six patients, and grade III in three
M. Trombetta et al.
206
Fig. 1 Skin dose utilizing central (single) lumen catheter only. (PTV_eval 97.7 %; maximum skin dose 121.6 % of
prescribed)
patients. The Harvard criteria, while reasonably

good in describing de novo cosmetic outcomes
following initial breast conservation therapy, are
inadequate in describing cosmesis in the retreated
breast as they do not allow for accurate description of the cosmetic effect of retreatment from a
standard baseline. It cannot do so by definition.
The Allegheny General Hospital (AGH) modification of the Harvard/NSABP scoring system
allows more accurate standardization of the
effects of repeat breast conservation by reestablishing a relative baseline. Cosmesis according to
the AGH modification of the Harvard criteria [54]
(Table 4) was more reflective of the changes
related solely to the retreatment: grade (1) in ten
patients, grade (2-2) in six patients, grade (3-3) in
two patients, grade (1-2) in one patient, and grade

(2-3) in one patient. The AGH modification highlighted that only two patients demonstrated cosmetic downgrading from retreatment irradiation.
Patient satisfaction was uniformly high as all
patients, when queried, were happy that they
chose the option of repeat preservation including
those who required salvage mastectomy.
Importance of the AGH

Modication
The Harvard criteria have been the most useful

cosmesis criteria accepted in the literature to
date. However, when trying to correlate outcomes
207
Fig. 2 Skin dose using multilumen catheter optimized for minimum skin dose (104 % of prescribed) and appropriate
dose to PTV_eval (95.2 %)
Table 3 NSABP breast cosmesis grading scale (Harvard criteria)
I. Excellent: when compared to the untreated breast, there is minimal or no difference in the size or shape of the
treated breast. The way the breasts feel (its texture) is the same or slightly different. There may be thickening, scar
tissue, or fluid accumulation within the breast, but not enough to change the appearance
II. Good: there is a slight difference in the size or shape of the treated breast as compared to the opposite breast or
the original appearance of the treated breast. There may be some mild reddening or darkening of the breast. The
thickening or scar tissue within the breast causes only a mild change in the shape or size
III. Fair: obvious difference in the size and shape of the treated breast. This change involves one quarter or less of
the breast. There can be moderate thickening or scar tissue of the skin and the breast, and there may be obvious
color changes
IV. Poor: marked change in the appearance of the treated breast involving more than one quarter of the breast
tissue. The skin changes may be obvious and detract from the appearance of the breast. Severe scarring and
thickening of the breast, which clearly alters the appearance of the breast, may be found
NSABP Protocol B-39 Form COS [39]
relative to retreatment, the Harvard criteria are

inadequate since they do not allow an adjustment
for the original cosmesis following the first con-
servation effort to set a standard for future comparison. The comparison of cosmetic terminology
between a surgically altered breast in the de novo
M. Trombetta et al.
208
Table 4 Allegheny modification of the Harvard/RTOG/NSABP criteria for the re-irradiated breast
A-0 (X). Where X = the breast cosmesis grade according to the Harvard/RTOG/NSABP criteria prior to repeat
surgical and radiotherapeutic intervention
A-1. When compared to the A-0 breast, there is minimal or no change in the size or shape of the retreated breast.
The breast texture is the same or slightly different. There may be thickening, scar tissue, or fluid accumulation
within the breast, but not enough to change the appearance
A-2. When compared to the A-0 breast, there is a slight difference in the size or shape of the treated breast as
compared to the opposite breast or the original appearance of the retreated breast. There may be some mild
reddening or darkening of the breast. The thickening or scar tissue within the breast causes only a mild change in
the shape or size
A-3. When compared to the A-0 breast, there is an obvious difference in the size and shape of the treated breast.
This change involves one quarter or less of the breast. There can be moderate thickening or scar tissue of the skin
and the breast, and there may be obvious color changes
A-4. When compared to the A-0 breast, there is marked change in the appearance of the treated breast involving
more than one quarter of the breast tissue. The skin changes may be obvious and detract from the appearance of the
breast. Severe scarring and thickening of the breast, which clearly alters the appearance of the breast, may be found
The initial scoring should consist of the A0 (X) score and all subsequent scores should be graded A0(X) followed
by the post-therapeutic A score [i.e., A (1-1) for excellent cosmesis pre- and postretreatment]. Initial scoring for
this same example would be graded as A (1-X) to denote the unknown future scoring
setting compared to a breast evaluated years after

surgery and postoperative irradiation followed by
the retreatment effects of both a second surgical
and radiotherapeutic intervention are intuitively
not equivalent.
This may be even more important when one
considers the variability in cosmetic outcomes
among different surgeons and radiation oncologists. Since many of these patients are referred to
and treated by tertiary and quaternary institutions, a wider variety of reported cosmetic outcomes is likely.
Complications
and Management
5.1
Acute and Subacute
The most frequent acute complication is mild

mastalgia at the balloon site which occurs
between 1 and 2 weeks post-explantation and
usually requires no therapeutic intervention. If
analgesia is desired, nonsteroidal antiinflammatory medications (NSAIDs) are preferred unless contraindicated. Wound infection or
abscess formation occurs rarely. Our experience
reflects approximately a 2 % rate of infection
which is generally managed by changing the
antibiotic coverage. Rare patients will develop a
non-healing wound which generally responds to

conservative expectant management.
5.2
Long Term and Chronic
The most common chronic side effects are sinus

tract formation and fat necrosis in the retreated
breast. Sinus tract formation has occurred in two
of our 22 patients, one of whom required mastectomy to remedy chronic pain and drainage. She
remains disease-free at 6 years postretreatment,
with very good postmastectomy healing and relative cosmesis. The second patient healed completely after 4 months with grade I cosmesis.
Four patients developed fat necrosis visible on
imaging studies, but asymptomatic. Fat necrosis
infrequently requires therapeutic intervention
[55]. When necessary, aspiration or, rarely, limited surgical resection will remedy the issue.
Generally we recommend conservative management with expectant observation and NSAIDs
with surgical management reserved only for the
rare patient with persistent and refractory mastalgia. Chronic cardiac dysfunction, having been
reported with external beam breast radiotherapy,
has not been encountered with intracavitary
brachytherapy and was shown to deliver minimal
cardiac dose, even in left-sided lesions [56].
Balloon brachytherapy has also been shown to be
safely used in patients with cardiac pacing and

defibrillating devices [57, 58] as long as the
approximate distance from balloon surface to the
pacing device is approximately 14 cm.
We are currently in the process of reducing the
total dose by reducing both the dose per fraction
and the number of fractions as are being done in
de novo single institutional trials. We do not
believe that a further volume reduction would be
safe or acceptable at this time; therefore, the volume parameters will remain unchanged.
Further Steps, Controversies,

and Summary
One of the most important controversies of IBTR

is the risk of systemic disease. This risk of systemic disease is correlated with the pathologic
features of IBTR but also with the notion that the
new breast event may be a true recurrence (TR) or
a new primary (NP) tumor. The difference
between the two entities is generally based on
pathologic and location information of the IBTR
compared to the original primary tumor but also
considers the time interval between primary and
recurrent tumor [59]. Indeed, this time interval
was reported as an independent prognostic factor
for DFS and OS with a cutoff ranging from 24 to
36 months [18, 60]. New molecular approaches
are proposed to refine more precisely the IBTR
features between NP and TR [61, 62]. However,
because it is often difficult to determine if the
IBTR is or is not a true recurrence, it is probably
better to speak in terms of a second ipsilateral
breast cancer event (IBCE) or a third IBCE, if any.
While there is a standard in terms of evidencebased medicine for considering conservative
treatment option for primary breast cancer [7, 8],
there is no significant proof for considering such
treatment as well as considering salvage radical
mastectomy as the standard treatment in the case
of IBTR. Could the concept of breast conservative
treatment be also considered for women
presenting with IBTR taking into account the fact
that the patient already underwent surgery, whole
breast irradiation, and various systemic therapies
for the primary? If a second BCT is proposed, in
209
regard to the presented results, this treatment

strategy should probably include re-irradiation of
the tumor bed. Consequently, in terms of clinical
research for achieving a high proof level, the
appropriate approach could be a randomized trial
comparing for IBTR, between salvage
mastectomy and second BCT with re-irradiation
of the tumor bed. However, for this type of
prospective phase III trial, what could be the best
statistical design: noninferiority or equivalence?
What could be the best primary end point: second
local recurrence rate, DFS, or OS? If such a phase
III trial was designed, the number of needed
patients for statistical significance would be high
(10002000 patients) for a nevertheless rare
event (IBTR) with the likelihood that patients
would not accept randomization between salvage
mastectomy and second BCT. Because a phase
III trial appears difficult to manage, the Radiation
Therapy Oncology Group (RTOG) proposed a
phase II prospective trial [14] which recently
closed due to complete completion of accrual
[14]. This trial is investigating toxicity (grade 3+
treatment-related skin, fibrosis, and mastalgia)
occurring within 1 year of re-irradiation (3-D
external beam radiation therapy) of the tumor bed
after salvage breast conservative surgery. The
radiation treatment volume consists of the
surgical cavity plus a 2.5 cm margin excluding
the skin surface. Twice daily fractions of 1.5 Gy
were administered to a total dose of 45 Gy. The
study will secondarily evaluate end points of
local control, freedom from mastectomy,
cosmesis, and overall survival.
The development and promotion of phase II trials for second BCT represent a pragmatic and
encouraging approach as it remains simple and feasible, with favorable inclusion criteria, a standard
re-irradiation technique, and accepted tolerance.
However, this clinical prospective research will not
allow any rigorous comparison with salvage mastectomy. Matched-pair analysis between salvage
mastectomy and second BCT could be a good
compromise to provide consistent but retrospective
realistic results. Currently, even if salvage mastectomy remains the historical local treatment, a case
can easily be made for retreatment breast conservation in favorable patients with IBTR.
M. Trombetta et al.
210
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Thoracic Brachytherapy
Paul Renz, Matthew Van Deusen,
Rodney J. Landreneau, and Athanasios Colonias
Abstract
Brachytherapy for thoracic malignancies provides localized

intrathoracic delivery of high-dose targeted radiotherapy, which can be
very potent as a primary treatment, an adjuvant treatment, or a salvage
treatment. We present our experience, data, and recommendations in
this regard.
P. Renz, DO
Department of Oncology, Allegheny General
Hospital, Pittsburgh, PA, USA
M. Van Deusen, MD
Department of Thoracic Surgery, Allegheny
General Hospital, Allegheny Health Network,
Pittsburgh, PA, USA
R.J. Landreneau, MD
Department of Thoracic Surgery, Allegheny General
Hospital, Allegheny Health Network,
Pittsburgh, PA, USA
A. Colonias, MD (*)
Department of Radiation Oncology, Allegheny
General Hospital, Allegheny Health Network,
Pittsburgh, PA, USA
Lung Cancer Brachytherapy
1.1
Incidence/Epidemiology
Lung cancer results in more cancer-related

deaths than any other malignancy in men and
women in the United States [1]. The American
Cancer Society estimates 221,200 new cases of
lung cancer will be diagnosed in the United
States in 2015. Lung cancer is the second most
common malignancy in men and women, following prostate and breast cancer, respectively,
and will account for an estimated 158,040 deaths
in the United States in 2015. Worldwide, lung
cancer accounted for 1.6 million cancer-related
deaths in 2012 [2].
Cigarette smoking is the most important risk factor in the development of lung cancer. It is estimated
to be the likely causative factor in up to 90 % of
patients [3]. Risk is increased with duration and
quantity of tobacco use. Cigar and pipe smoking are
also associated with increased risk of developing
lung cancer, as is exposure to second hand smoke.

DOI 10.1007/978-3-319-26791-3_12
213
P. Renz et al.
214
Environmental factors, including exposure to radon

gas and various occupational exposures, also contribute to the development of lung cancer [3].
1.2
Diagnosis and Staging
Non-small cell lung cancer (NSCLC) accounts

for approximately 80 % of all lung cancers.
Adenocarcinoma, squamous cell carcinoma, and
large-cell carcinoma are the most common types
of non-small cell lung cancer. Small cell lung
cancer (SCLC) accounts for approximately 15 %
of all lung cancers. Accurate diagnosis and staging are of critical importance in the determination of staging, treatment, and prognosis.
Lung cancer is staged according to the
American Joint Committee on Cancer (AJCC)
seventh edition of the tumor-node-metastasis
(TNM) classification system [4]. Clinical, radiographic, and pathologic criteria are utilized.
Tumor status is primarily dependent on the size
of the tumor. Other factors, including tumor location, involvement of visceral and parietal pleura,
the presence of post-obstructive pneumonia, and
the presence (and location) of satellite nodules,
are considered. Nodal status is dependent on the
location of involved nodal stations: hilar, ipsilateral mediastinal, contralateral mediastinal, and
ipsilateral supraclavicular. Metastasis relates to
the presence of distant disease or the presence of
a malignant pleural effusion.
Appropriate imaging routinely includes CT
and PET scan evaluations. These allow evaluation
of the primary lung lesion and associated hilar and
mediastinal adenopathy, as well as the presence
of distant disease. Invasive testing is commonly
performed to obtain an initial diagnosis of lung
cancer. Typically, bronchoscopic evaluation and
CT-guided needle biopsy are utilized. Additional
modalities are considered in the assessment of
hilar and mediastinal lymphadenopathy. These
may include traditional bronchoscopy with transbronchial needle biopsies, endobronchial ultrasound, or endoscopic ultrasound-guided biopsies,
as well as surgical procedures, including mediastinoscopy, anterior mediastinotomy, or thoracoscopic surgical evaluation. Distant disease, when
suspected, generally requires pathologic confirmation. Depending on the presentation, invasive

techniques may include image-guided percutaneous biopsy, drainage of associated pleural or
pericardial effusion, or surgical evaluation of an
extrathoracic lesion.
1.3
Treatment Overview
The TNM stage at presentation is the greatest

determinant of prognosis. Early-stage disease is
associated with favorable survival compared with
later-stage disease. The changes to the seventh
edition of the AJCC TNM staging guide reflect
these survival differences [4].
For medically operable candidates with earlystage disease (stage I and II), the mainstay of therapy is surgical resection with lymph node staging.
The extent of resection is dependent on the size
and location of the lesion and the patients cardiopulmonary status. It may include sublobar resection (nonanatomic wedge resection or anatomic
segmentectomy), lobectomy, bilobectomy, or
pneumonectomy. Various approaches to surgical
resection are available, with comparable safety
and oncologic outcomes. These include open
thoracotomy approaches and minimally invasive,
video-assisted techniques. Postoperative adjuvant
platinum-based chemotherapy is routinely considered in patients with pathologic stage II disease and may be of benefit in some patients with
pathologic stage Ib (patients with tumors >4 cm)
[57]. Adjuvant radiation is a consideration in the
setting of incomplete resection.
Medically inoperable candidates with earlystage disease (stage I) may be candidates for a
variety of nonsurgical ablative therapies, including stereotactic body radiation therapy (SBRT)
or stereotactic ablative body radiation (SABR),
radio-frequency ablation (RFA), microwave ablation, or cryotherapy. Systemic platinum-based
chemotherapy is offered to medically inoperable
candidates with locally advanced disease (stage
II), as these nonsurgical ablative therapies do not
address hilar nodal disease.
For patients with advanced-stage disease (stage III), multimodality treatment with
platinum-based chemotherapy and radiation

therapy is typically recommended. This may be
a definitive treatment strategy or a neoadjuvant
(induction) treatment strategy followed by surgical resection in selected patients.
Patients with metastatic disease (stage IV)
are treated medically with platinum-based chemotherapy. Palliative treatment of symptomatic
disease is a consideration. This may include
endobronchial therapies (airway stenting, laser
therapy, photodynamic therapy, high-dose rate
brachytherapy, and cryotherapy) for palliation of
airway obstruction or bleeding, management of
malignant pleural effusions (chemical pleurodesis or chronic pleural drainage) for palliation of
dyspnea and shortness of breath, and radiation
therapy for palliation of painful metastatic bone
lesions or other indications.
Background/History
of Thoracic Brachytherapy
Lung brachytherapy as a treatment technique for

various stages of lung cancer dates back to the
1920s. In 1922, Yankauer published the first
report on brachytherapy for lung cancer as they
treated two patients with radium-226 [8]. Several
years later in 1929, Kernan and Cracovaner further described lung brachytherapy with the
implantation of three radon-222 seeds into a
malignant endobronchial tumor in a 35-year-old
woman [9]. He subsequently reported eight additional cases of endoluminal interstitial radon-222
seed implantation by rigid bronchoscopy and in
conjunction with diathermy [10]. Remarkably,
five of the eight patients lived beyond 2 years with
this treatment.
In parallel with the cases reported by Kernan,
his contemporaries were also performing this
exciting new technique. Pool et al. reported their
experience at the Memorial Hospital with 42
patients permanently implanted with hollow gold
seeds filled with radon-222 gas from 1936 to
1960 in a variety of tracheobronchial locations as
both an adjunct to surgery and as primary therapy
[11]. In 1932, Graham and Sanger performed a
radical pneumonectomy with mediastinal nodal
215
dissection for a 1.0 cm left mainstem bronchus

squamous cell carcinoma. They utilized the
cutting edge technology of their time as they
implanted seven radon seeds with activity of
10.5 mCi into the bronchial stump [12].
Despite some initial success with brachytherapy and rigid bronchoscopy, the technique was
fraught with technical difficulty. Uniform dose
distribution and precise geometric arrangement
of sources was difficult to produce due to limited range of motion using rigid bronchoscopy.
Seeds were often times placed superficially and
expectorated or, conversely, placed too deep and
within the chest cavity or lung parenchyma. In
addition, perioperative hemorrhage and airway
edema complicated the procedure as severe acute
side effects [1117]. Over time lung brachytherapy was refined as applicators for endoluminal
brachytherapy were developed for use with flexible bronchoscopy. In the early 1980s, Mendiondo
et al. described the first true endoluminal brachytherapy with a low-dose rate (LDR) afterloading
system [18]. Further advances in remote afterloading systems and high-dose rate sources then
ushered us into endoluminal treatments as most
centers perform today [19, 20]. High-dose rate
(HDR) endobronchial brachytherapy (EBBT)
solved many shortcomings of its predecessors as
a less invasive modality with decreased treatment
times and lessened staff radiation exposure.
Endoluminal Brachytherapy
in Lung Cancer
3.1
Low-Dose Rate (LDR) Versus

High-Dose Rate (HDR)
Brachytherapy
With the advent of computerized remote HDR

(>2 Gy/min) afterloading systems, LDR
(<2 Gy/h) endoluminal brachytherapy gave way
to the enhanced patient convenience and radiation safety of HDR treatments [21]. HDR treatment could be performed on an outpatient basis
and in an expedient fashion. Patient satisfaction
and comfort were increased by the lack of need
for indwelling endobronchial catheters for
P. Renz et al.
216
extended time periods of up to 4872 h. Treatment

was able to be performed in shielded vaults and
did not pose the radiation safety hazards to hospital staff of LDR treatment. Needless to say, the
question remained: Is HDR equivalent to LDR in
terms of safety and efficacy for the treatment of
lung cancer?
Lo et al. compared the outcomes of patients
treated with LDR and HDR showing equal efficacy and toxicity [22, 23]. They compared their
experience of 110 patients treated with LDR
endoluminal brachytherapy for malignant airway
obstruction prior to the advent of HDR treatments
with a cohort of 110 patients treated with HDR
endoluminal brachytherapy. Their results showed
no significant difference in bronchoscopic
response or complications between the two
cohorts [22, 23].
With the available evidence showing equal
response and toxicity, it is a reasonable conclusion that HDR endoluminal brachytherapy is the
preferred brachytherapy modality (when available) given its ease of use, patient convenience,
and better radiation safety profile.
3.2
HDR Technique
Endobronchial brachytherapy is performed on an

outpatient or inpatient basis with the assistance of
either a pulmonologist or thoracic surgeon. The
patient is brought to either the bronchoscopy suite
or operating room and sedated. In most situations,
the patient is not intubated. A face mask with
high-flow oxygen is placed over the patients open
mouth. A flexible bronchoscope is then placed
into the patients nostril and passed through the
nasopharynx and into the patients larynx. The
true vocal cords are then anesthetized with lidocaine passed through the bronchoscope. It is also
helpful to anesthetize the carina with additional
lidocaine to prevent coughing in the recovery
room and/or radiation oncology department. The
patients bronchial tree is then fully inspected by
the bronchoscopist with particular attention to the
endobronchial lesion to be treated.
The next step is crucial for accurate treatment
planning. The bronchoscopist must then make
Fig. 1 Endobronchial lesion from renal cell carcinoma

metastasis (arrow) with adjacent endobronchial catheter
placed under bronchoscopic direct visualization
measurements of the length and width of the

endobronchial disease as well as the distance
from the proximal end of the lesion to the carina.
Additional measurements that provide useful
information include the distance from carina to
the distal extent of the endobronchial lesion.
These measurements must be obtained prior to
insertion of brachytherapy catheter through the
bronchoscope. It is also important to note any
anatomical branch points of the secondary or tertiary bronchi in proximity to the lesion as a further reference point.
After appropriate measurements are made, the
brachytherapy catheter is then placed. The
brachytherapy catheter (5 or 6 French) is placed
through a port in the bronchoscope. It is placed
distal to the lesion under direct visualization
(Fig. 1). The distal extent of the catheter is identified by a radiopaque plug at the end of the catheter. Fluoroscopic images are obtained to verify
the desired final position of the catheter (Fig. 2).
The catheter should be placed at least 34 cm
past the distal extent of the lesion, yet special
attention must be made to not pass the catheter
onto the pleural surface as this may cause a pneumothorax or pleuritic chest pain. The catheter tip
must not coil, and if so, a guide wire may be used
to aid in placement and prevent coiling. In order
to avoid the catheter laying directly onto the
bronchial wall and especially when in close
Fig. 2 Digitally reconstructed AP radiograph showing

the brachytherapy catheter in the left lower lobe bronchus
(arrow)
proximity to mediastinal vessels, the catheter

may be placed inside a silicone tube such as a
thin nasogastric tube which acts as a spacing buffer avoiding high dose to that immediate bronchial wall [24]. On occasion when treating
endobronchial lesions at the bifurcation of two
bronchi, a catheter may be placed within each
bronchus to achieve better dose distribution to
the target [24, 25]. When removing the bronchoscope, the brachytherapy catheter is then visualized under continuous fluoroscopy to verify that
the catheter is not displaced and remains in the
correct anatomic alignment.
The catheter is then fixed to the patients nose
with adhesive tape. Helpful techniques are using
tincture of benzoin to add extra adhesive to the
patients nose and the catheter itself. The catheter
is then marked at a length distal to the taping, and
the distance from the tip of the patients nose to
that mark is recorded as the reference to assure
the catheter position. The remaining length of the
catheter is then taped to the patients forehead or
scalp. Special instructions/education should then
be given to all involved personnel on the purpose
of the catheter and the importance of its static
fixation.
After recovery from anesthesia, the patient is
then taken to the radiation oncology department.
217
Dummy sources are placed through the catheter

and a simulation is performed with a CT scan of
the neck and chest without contrast. Prior to the
CT, the catheter length is verified using a guide
wire and verifying that the actual length coincides
with the manufacturers reported length. Medical
physics and dosimetry then upload the CT
simulation data set to a brachytherapy-based
treatment planning system. The radiation
oncologist prescribes a dose to a depth over the
length of the lesion with a margin proximally and
distally. Dosing varies dependent on numerous
patient/tumor factors including location of lesion,
prior treatment history, size of lesion, and
occasionally diameter of the bronchial lumen. A
commonly prescribed depth is 1 cm and a
common margin is 2 cm proximal and distal to
the lesion. The plan is then generated based on
TG-43 (Fig. 3) and quality assurance is ascertained [26].
The patient is then ready for treatment and is
taken to a shielded vault. The position of the
catheter is verified. A remote afterloading HDR
unit is then connected with the catheter (Fig. 4).
Remote afterloading systems are extremely
sensitive to detect the end of the catheter. This
may be problematic if sharp angles, such as those
seen with lesions in upper lobe bronchi, cause the
system to detect the bend/angle at the end of the
catheter. A computer-controlled HDR source,
such as Ir-192, is then remotely passed by the
afterloader to the desired location in the catheter,
and treatment is delivered. The duration of
treatment varies depending on the isotope used
and its activity as well as the treatment length,
depth, and dose. Usually the treatment is
delivered over an approximately 510 min time
period. Afterward the HDR source is remotely
removed and stored within the afterloader. A
radiation survey of the treatment room and
patient is then conducted to insure the radioactive
source is within the shielded afterloader. After
successful treatment, the brachytherapy catheter
is then removed and the patient is monitored for a
brief period of time before being discharged for
the next fraction of treatment. Auscultation of all
lung fields and vital signs are checked after
treatment and prior to discharge.
P. Renz et al.
218
ically occult endobronchial cancer; however, it

has also been used definitively to treat as a
boost with external beam, for postoperative
adjuvant therapy and for definitive treatment of
isolated recurrent disease [27, 28]. Furthermore,
almost all cases of definitive treatment with
EBBT are resigned to treatment of non-small
cell cancer histology with the rare exception of
tumors such as adenoid cystic or carcinoid
tumors. For the purposes of this discussion, we
will be referring to non-small cell lung cancer
(NSCLC) exclusively.
4.2
Fig. 3 Plan of an HDR treatment delivering 600 cGy to a

1 cm depth and a 7 cm treatment length to the left lower
airway
Fig. 4 Patient at the afterloading HDR brachytherapy

unit ready to receive treatment
Indications for HDR

Endoluminal Brachytherapy
(EBBT)
4.1
Denitive EBBT
Endobronchial brachytherapy has been utilized

in a definitive fashion in a number of settings.
It is perhaps best described as an effective
modality for the rare entity of roentgenograph-
Denitive: EBBT Monotherapy
Endobronchial brachytherapy (EBBT) alone as a

treatment for NSCLC has been reported in a number of series as shown in Table 1. Selection criteria
for definitive EBBT treatment should be strict and
include early-stage disease (Tis/T1), small
(<1.0 cm) tumors, and node-negative, nonmetastatic, and radiographically occult lesions. These
patients should be evaluated for resection and must
either not be surgical candidates or refuse resection
as surgery remains the standard of care.
Furthermore, adequate nodal staging with imaging
such as PET-CT and pathologic assessment with
mediastinoscopy is warranted unless contraindicated prior to definitive EBBT. Factors that have
been associated with a lower incidence of nodal
metastasis include tumor size <1.0 cm and squamous cell cancer histology and therefore are characteristics that lend well to definitive local therapy
alone [27, 28].
Marsiglia et al. treated 34 inoperable patients
definitively with EBBT alone that had predominant
squamous cell histology with an average tumor size
of 1.0 0.5 0.3 cm [24]. The patients received
definitive EBBT to a total dose of 30 Gy in six fractions with a 2-year local control and survival rate of
85 % and 78 %, respectively. The unique aspect of
their study was individualized prescription dosing
and adherence to techniques eliminating catheter
contact with the bronchial mucosa. Accordingly,
they achieved no treatment-related late toxicity of
hemoptysis or bronchial necrosis. Their one case of
fatal hemoptysis was attributed to a transbronchial
biopsy in a patient with no evidence of tumor or
219
Table 1 HDR endobronchial brachytherapy treatment as sole modality in NSCLC

Dose (Gy
at 1 cm)
15 or 20
Fractions
1
Response
Not reported
Small
endobronchial
tumors
810
34
96 %
endoscopic
CR
34
(97 %
SCC)
106
(95 %
SCC)
Average size
1.0 0.5 0.3 cm
5a
2-yr LC 85 %
1.9 cm mean
length
5 or 7
226
(96 %
SCC)
Tis = 27 %
T1 = 68 %
47
46
81 %
endoscopic
CR
2-yr LC 60 %
93.6 %
endoscopic
CR
Study
Gollins [29, 30]
N
37
(84 %
SCC)
Size
<2.0 cm
Tauelle [31]
22
(84 %
SCC)
Marsiglia
[24]
Hennequin
[32]
Aumont-Le
Guilcher [33]
Survival
2-yr OS
49.4 %
5-yr OS
14.1 %
1-yr OS
71 %
2-yr OS
46 %
2-yr OS
78 %
3-yr OS
47 %
5-yr OS
24 %
2-yr OS
57 %
5-yr OS
29 %
Complications
13.5 % fatal
hemoptysis
7 % massive
hemoptysis
4 % necrosis
1 case of fatal
hemoptysis
2 % fatal
hemoptysis
3 % fatal
necrosis
5 % fatal
hemoptysis
4 % necrosis
SCC squamous cell carcinoma of lung, CR complete response, LC local control, EBBT endobronchial brachytherapy,
Endoscopic CR macroscopic negative findings on repeat bronchoscopy at 3 months, 2-yr OS 2-year overall survival,
3-yr OS 3-year overall survival, 5-yr OS 5-year overall survival, CR complete response, LC local control
a
Prescribed at 0.51.0 cm
bronchial necrosis. They concluded that EBBT was

a treatment option in nonoperable patients with
early, small NSCLC [24].
Hennequin et al. treated 106 patients not suitable
for surgery or further EBRT with definitive HDREBBT to total doses between 30 and 42 Gy in six
fractions, prescribed to a 1.0 cm depth [32]. They
noted a 59.4 % complete histologic response at 3
months and a 3-year overall survival (OS) of
47.4 %. A total of five fatal events attributed to treatment (two hemoptyses and three bronchial necroses) occurred. Predictors of local failure included
tumors greater than 2.0 cm and/or occlusion of
>25 % of the bronchial lumen. They concluded that
HDR-EBBT can be considered a curative modality
for early-stage endobronchial NSCLC [32].
More recently, Aumont-Le Guilcher et al.
published a series of 226 inoperable patients with
Tis, T1, and T2 NSCLC treated definitively with
HDR-EBBT to total doses ranging from 24 to
35 Gy in 46 fractions [33]. They noted a complete endoscopic response rate of 93.6 % at 3
months with median overall survival of
28.6 months. Also noted was a 5 % incidence of
fatal hemoptysis, and they concluded that HDR-
EBBT was a safe and effective treatment for

inoperable endobronchial carcinoma [33].
In summary, EBBT as sole definitive treatment
for early-stage endobronchial NSCLC is not standard of care, but may be utilized in certain situations where other more conventional options such
as surgery and stereotactic body radiotherapy cannot be utilized. Patient selection is quite important
with most reported series having a predilection for
squamous cell histology, radiographic occult cancers, no evidence of nodal metastasis on staging,
and small (<12 cm) lesions. The reported series in
the literature vary significantly in dosing regimens.
The American Brachytherapy Society recommends either a total dose of 22.5 Gy in three fractions or 25 Gy in five fractions prescribed to a 1 cm
depth for well-selected patients [34].
4.3
Denitive: External Beam

Radiotherapy (EBRT) + EBBT
Endobronchial brachytherapy has been combined

with external beam radiotherapy in a number of
reports as outlined in Table 2 [3543].
P. Renz et al.
220
Table 2 Select studies of combined EBRT/EBBT for definitive treatment of NSCLC
Study
Aygun [35]
Nori [36]
Huber [37]
Anacak [38]
Langendijk [39]
Gejerman [40]
Ozkok [41]
Rochet [42]
EBRT
N
Stage
(Gy)
67
IIIIB
5060
17 (group 1) IIIB
50
56
IIIAIV 50 + 10
boost
30
III
60
47
IIIIB
3060
33
IIIIV
37.5
43 (group A) III
60
35
IIII
50
HDREBBT (at
1 cm depth)
35 5 Gy
3 5 Gy
2 4.8 Gy
Median overall
survival
Response
(months)
LC 3675 % 13
LC 88 %
17.7
NR
40 weeks
Hemoptysis (%)
15
0
18.9
3 5 Gy
2 7.5 Gy
3 5 Gy
3 5 Gy
3 5 Gy
CR 53.3 %
NR
BR 54 %
CR 67 %
CR 57 %
10.5
15
0
5
9
11
7.0
5.2
11
39.1
NSCLC non-small cell lung cancer, EBRT external beam radiotherapy, HDR-EBBT high-dose rate endobronchial
brachytherapy, LC local control, NR not reported, CR complete response, BR bronchoscopic response, Hemoptysis
reported massive or fatal hemoptysis
Endobronchial brachytherapy as a boost to EBRT

in advanced non-small cell lung cancer patients
may improve local control in select patients, particularly with squamous cell histology. Huber
et al. conducted a randomized prospective trial
with 98 nonoperable advanced-stage non-small
cell lung cancer patients randomized to 60 Gy of
external beam radiotherapy with or without a
4.8 Gy HDR-EBBT boost 1 week before and 3
weeks after completion of EBRT. With a median
follow-up of 2.5 years, there was no statistically
significant difference in overall survival or toxicity; however, there was a trend toward a local control benefit, especially in patients with squamous
cell histology with EBBT [37].
Several studies have shown durable palliation
of symptoms when adding EBBT to definitive
external beam therapy in locally advanced nonsmall cell lung cancer patients. Langendijk et al.
conducted a randomized prospective trial of 95
newly diagnosed stage IIIIB NSCLC patients
having proximal tumors with an endobronchial
component treated definitively with EBRT +/
EBBT [39]. They showed no difference in survival or toxicity, but did reveal a statistically
significant improvement in relief of dyspnea longer than 3 months, in re-expansion of atelectactic
lung (57 % vs. 35 %), and improvement in inspiratory vital capacity with the addition of
EBBT. They concluded that addition of EBBT to
definitive radiotherapy improves symptomatic
dyspnea without added toxicity [39]. Anacak

et al. similarly published a phase II prospective
study of 30 newly diagnosed stage III NSCLC
patients treated with EBRT to a total dose of
60 Gy with an HDR-EBBT boost of 15 Gy in
three fractions showing symptomatic relief of
cough, hemoptysis, chest pain, and dyspnea [38].
Gejerman et al. also showed overall symptomatic
improvement of 72 % in 33 NSCLC patients
treated with EBRT + EBBT boost [40].
HDR-EBBT as an adjunct/boost to external
beam radiation in the nonoperative definitive
management of locally advanced NSCLC has not
translated into a survival benefit [3543].
Furthermore, studies of EBRT + EBBT do not
include concurrent chemotherapy as part of the
treatment regimen which is the current standard
of care. Accordingly, definitive treatment of
locally advanced NSCLC remains chemoradiation with EBBT reserved for palliation of
symptoms.
4.4
Denitive: Postoperative EBBT
Definitive adjuvant HDR-EBBT in the postoperative setting for close or positive margins has also
been described. Skowronek et al. described a heterogeneous group of 34 patients with positive margins or bronchial stump recurrence treated
definitively with HDR-EBBT. They reported a
73.5 % complete response rate and a median overall survival of 18.8 months. Such therapy, however,
is not considered a standard of care. Further options
to also be considered include further surgery, external beam radiation, and chemotherapy [44].
4.5
Palliation
Despite definitive treatment, many patients

with NSCLC and lung metastasis alike present
with symptomatic airway obstruction. EBBT is
best known for its use as a palliative modality.
Although most series describe palliation of primary lung malignancy, EBBT has been effective
in palliation of metastatic disease as well [45].
Endobronchial brachytherapys characteristics
of rapid dose falloff make it ideal for palliation
of endobronchial lesions, as normal tissue is
spared excess radiation dose thereby minimizing side effects. Symptoms from endobronchial
obstruction such as cough, hemoptysis, dyspnea,
and lung collapse are palliated effectively with
EBBT; however, symptoms of chest pain and
dysphagia may not be as effectively palliated
with EBBT as they are often caused by bulky
extrinsic lung masses rather than endobronchial
disease [46]. When considering palliation of lung
malignancy, external beam radiotherapy has been
found to provide effective symptom relief [47].
Yet, there still remains a subset of patients that
may benefit from EBBT such as those patients
with prior history of EBRT or poor pulmonary
reserve precluding EBRT. Multidisciplinary
treatment teams including thoracic surgeons,
internists, pulmonologists, and medical and radiation oncologists must choose which patients to
select for EBBT based on acuity of symptoms,
size/location of disease, life expectancy, performance status, potential toxicity, and prior/future
treatments.
Endobronchial brachytherapy has been found
to be effective in providing prompt and durable
symptom control. Symptom relief can be
obtained as early as 2448 h after EBBT [48],
and many studies have shown duration of relief
for approximately 612 months [29, 49, 50].
Accordingly, with this enhanced duration of
221
symptom relief, many series have shown a

decreased need for further EBRT and/or bronchoscopic interventions [29, 50]. Overall symptom relief after brachytherapy is approximately
7090 % [27, 51]. Mallick et al. have shown
increased quality of life (QOL) with EBBT [52].
Hemoptysis, dyspnea, cough, and atelectasis
show 67100 %, 33100 %, 4688 %, and
2083 % improvement after EBBT, respectively,
based on standardized symptom scoring in a
number of series as detailed in Table 3 [29, 31,
36, 41, 45, 46, 49, 5361].
Endobronchial brachytherapy may be safely
utilized in combination with multiple therapies
such as Nd:YAG laser photocoagulation, photodynamic therapy, stenting, or EBRT [62]. Patients
with symptomatic lung lesions are a difficult
challenge to provide adequate palliation, and
multimodality approaches have been shown to be
beneficial [62]. Laser photocoagulation has
shown to be safe and effective in combination
with EBBT [50, 63, 64]. Photodynamic therapy
has been used in combination with EBBT with no
increased toxicity and enhanced duration of benefit indicating a synergistic effect [65, 66]. Most
often EBBT is used in conjunction with EBRT,
and this has also proven safe in a number of series
when conventional EBBT dose and fractionations
are used [27, 36, 41, 67]. Multimodality aggressive airway management with multiple combined
treatment modalities has been shown to be beneficial, and EBBT is safely utilized in conjunction
with other modalities [62].
When treating in a palliative fashion, toxicity of
treatment must be minimized. With EBBT, acute
toxicity including pleuritic chest pain, pneumothorax, bronchospasm, and bronchitis are infrequent
[36, 51, 67]. Late toxicity includes bronchial stenosis, pneumonitis, dysphagia, odynophagia, bronchial necrosis, fistula, and hemoptysis. Bronchial
necrosis, fistula, and hemoptysis are devastating
toxicities of treatment. The true incidence of massive or fatal hemoptysis after EBBT is unclear.
Reports cite rates between 0 and 32 %, but more
modern series with acceptable dosing and fractionation schedules have rates closer to 510 % [29, 36,
49, 50, 53, 67, 68]. However, the true incidence of
iatrogenic hemoptysis is clouded by the high inci-
P. Renz et al.
222
Table 3 Palliative HDR endobronchial brachytherapy treatment
Study
Burt [46]
Bedwinek [53]
Speiser [54]
Nori [36]
Pisch [55]
Chang [49]
Gollins [29]
Kohek [56]
Tredaniel [57]
Ofiara [58]
Taulelle [31]
Quantrill [45]
EscobarSacristan [59]
Kubaszewska [60]
Ozkok [41]
Guarnechelli [61]
EBBT dose
per fraction
(Gy) at 1 cm
Prior or
concurrent
EBBT
N
50
38
295
32
39
76
406
79
51
30
131
37
81
1520
6
7.510
5
10
7
1020
5
7
8
810
1020
5a
Fractions
1
3
3
3
12
3
1
15
2
3
34
1
4
98 %
100 %
41 %
100 %
85 %
78 %
20 %
68 %
63 %
100 %
62 %
11 %
63 %
Percentage of palliation in patients with

presenting symptoms
Hemoptysis Dyspnea Cough Atelectasis
86
64
50
46
80
71
80
64
99
86
85
100
100
86
44
93
80
20
95
87
79
88
60
62
46
86
67
70
70
85
55
85
79
33
46
43
74
54
54
67
42
50
96
75
88
270
158
52
810a
57.5
57.5
14
23
13
86 %
100 %
100 %
92
100
94
76
77
77
58
64
73
0.51.0 cm depth
dence of recurrent disease in patients who develop

post-EBBT hemoptysis. When accounting for this,
published rates of hemoptysis are lower at around
5 % [68, 69]. Factors associated with increased risk
of hemoptysis include dosing, fraction size, performance status, proximity to mediastinal vessels, history of chemotherapy (concurrent and/or
sequential), and prior EBRT [53, 69].
Overall, EBBT is a well-tolerated and safe treatment for the palliation of airway obstruction in
select patients with endobronchial disease. It is
effective in palliating symptoms of dyspnea,
hemoptysis, cough, and atelectasis with long-lasting
duration of relief [29, 49, 50]. The risk of causing
massive/fatal hemoptysis must be considered, and
particular attention should be paid to past and ongoing treatments to mitigate this risk and therefore
dose/fractionate accordingly. Common treatment
regimens for palliation include 47.5 Gy/fraction
for 24 fractions. Table 4 reviews the American
Brachytherapy Societys dosing recommendations
[34]. Dosing should be adjusted depending on prior
treatment history and concurrent chemotherapy
administration should be avoided.
4.6
EBBT and Benign Disease
Although endobronchial brachytherapy (EBBT)

is a modality used almost exclusively for
malignant disease, there remains a select group of
refractory benign conditions in which EBBT may
be considered as a treatment option. These benign
conditions include airway stenosis secondary to
hyperplastic granulation tissue post-lung transplantation, post-intubation tracheomalacia, bronchomalacia from various inflammatory causes,
and benign complex tracheobronchial stenosis
due to tuberculosis [7080]. The literature on
brachytherapy for benign disease should be interpreted with some caution, as there are limited
patient numbers and the groups are heterogeneous
in terms of HDR-EBBT dosing. In all benign disease, the risk of acute and late radiation toxicity
and risk of long-term oncogenesis must be
weighed against the potential therapeutic benefit.
Accordingly, most if not all of the literature supporting EBBT in benign disease occurs after
many attempts at conservative management have
failed.
223
Table 4 ABS dosing recommendations for HDR and LDR endobronchial brachytherapy based on intent of treatment
Palliative intent alone
Palliative intent combined with EBRT (30 Gy in 1012

fractions)
Definitive intent alone
Definitive intent combined with EBRT (60 Gy in 30
fractions)
HDR dosinga
6 Gy 4 fractions
7.5 Gy 3 fractions
10 Gy 2 fractions
4 Gy 4 fractions
5 Gy 3 fractions
7.5 Gy 2 fractions
5 Gy 5 fractions
7.5 Gy 3 fractions
5 Gy 3 fractions
7.5 Gy 3 fractions
LDR dosing
30 Gy to a 1 cm depth
2025 Gy to a 1 cm depth
Not reported
Not reported
a
Level of evidence: category 2; 1 cm prescribed depth, fractions given every 12 weeks, reduce dose if sequential/concurrent chemotherapy is administered
Radiobiologically, hyperplastic granulation

and tracheobronchial malacia as insults from
disruptive inflammation can be therapeutically
targeted by radiotherapy. Radiation is thought to
interrupt macrophage migration within the first
4872 h after an inflammatory response mounts
[73, 78]. This causes downstream alteration in
the inflammatory microenvironment and cytokine production which is theoretically responsible for the benign stenosis in question [73, 78].
Tendulkar et al. reported the successful treatment
of eight patients with benign airway obstruction
due to granulation tissue treated with HDREBBT within 4872 h of bronchoscopic debridement [79]. This indicates that for HDR-EBBT to
be effective in benign disease, first the obstruction must be debrided followed by prompt HDREBBT within 48 h for adequate disruption of the
pathogenic inflammatory response.
There are several published reports of the use
of EBBT in the treatment of hyperplastic
granulation tissue causing airway obstruction in
the setting of lung transplantation. Bronchial
stenosis due to hyperplastic granulation tissue at
the anastomotic site is a common complication
occurring in approximately 715 % of patients
post-lung transplant [73]. This complication is
usually managed conservatively; however, when
refractory, EBBT has been shown to be an option
in select cases [72, 73, 75, 76].
Kennedy et al. reported two cases of symptomatic airway obstruction from anastomotic
stenosis and malacia post-lung transplantation.
Both patients failed stenting, laser ablation, and
dilation attempts. They performed HDR-EBBT

delivering 12 fractions of 3 Gy/fraction to a
1.0 cm depth. At 6 and 7 months, they reported
successful resolution of symptomatic obstruction
and stenosis on repeat bronchoscopy with no toxicity of treatment [73].
Halkos et al. reported four cases of refractory
anastomotic airway obstruction posttransplantation treated with HDR-EBBT after stenting and
laser or electrocautery debridement. A dose of
3 Gy/fraction in 24 fractions was prescribed to a
1 cm depth with a treated length approximately
0.5 cm proximal and distal to the area at risk
determined by thoracic surgery at time of bronchoscopy [72]. In their report, two patients had a
significant response, one patient had a partial
response, and no patient experienced toxicity
from EBBT [72].
Similarly, Madu et al. reported HDR-EBBT
treatment of four post-lung transplant patients
with benign bronchial obstruction due to
hyperplastic granulation tissue and one patient
with tracheal stenosis/obstruction due to prolonged intubation [75]. They reported success in
symptomatic relief, increase in posttreatment
FEV1, and significant decreased quantity of
interventional bronchoscopic procedures postbrachytherapy. They prescribed total doses
ranging between 10 and 21 Gy in 57Gy
treatment fractions. One patient did experience
nonfatal radiation-induced bronchitis [75].
Meyer et al. described the largest series to
date of 12 post-lung transplant patients with
benign airway obstruction with mean follow-up
P. Renz et al.
224
of 34.1 months [76]. HDR-EBBT was delivered

in 14 fractions of 3 Gy/fraction to a prescribed
depth of 0.51.0 cm and treatment length 0.5 cm
proximal and distal to the area at risk. They
reported symptomatic improvement in dyspnea,
improved quality of life, and a decreased number of bronchoscopic interventions as well as a
statistically significant (p < 0.02) improvement in
mean FEV1 in all patients after HDR-EBBT with
no brachytherapy-related complications [76].
Nonmalignant airway obstruction due to
hyperplastic granulation tissue and bronchomalacia is not restricted to only the post-lung transplant setting. Kramer et al. reported a case of a
19-year-old male with airway obstruction due to
hyperplastic granulation tissue after airway
trauma, prolonged intubation, and stent placement [74]. After failure of other measures, they
successfully used HDR-EBBT with a single
application of 10 Gy prescribed to a 1 cm depth
with long-lasting airway patency [74]. The largest
series of HDR-EBBT for benign disease was published in 2012 by Allen and colleagues [70]. They
published a series of 29 patients with hyperplastic
granulation tissue of the trachea caused mostly by
prolonged intubation and mechanical ventilation.
Patients were treated with a single fraction of
HDR-EBBT to a dose of 10 Gy prescribed to a
1 cm depth with 66 % achieving resolution of
granulation with median follow-up of 36 months
[70]. Similarly, Rahman et al. published a series
of 28 patients with refractory airway obstruction
due to prolonged mechanical ventilation treated
with a single HDR-EBBT fraction to a dose of
10 Gy [77]. Post-brachytherapy, all patients had a
decreased need for interventional bronchoscopic
procedures with no associated treatment-related
toxicity.
In summary, limited reported series have
shown a potential role for HDR-EBBT in the
treatment of benign airway obstruction caused
by hyperplastic granulation tissue post-lung
transplantation, post-intubation tracheomalacia,
and bronchomalacia from various inflammatory
conditions when other measures have failed.
These reports should be interpreted with some
caution as they have limited patient numbers and
are heterogeneous in terms of HDR-EBBT dos-
ing. The potential risk of HDR-EBBT-induced

oncogenesis must also be addressed when considering HDR-EBBT in the treatment of these
benign conditions.
Conclusions
HDR endobronchial brachytherapy can be a useful treatment modality for lung cancer and is
commonly used in the palliative setting for endobronchial malignant airway obstruction and in
select circumstances for definitive management.
In the hands of an experienced bronchoscopist and
radiation oncologist, it is well tolerated and can be
performed on an outpatient basis. The published
reports of EBBT are heterogeneous in terms of
dosing and fractionation and vary depending on
the extent of prior treatment (prior external beam
radiation/chemotherapy), patient performance status, extent of disease, and intent of treatment. In
general, HDR brachytherapy is performed every
12 weeks and usually prescribed to a 1 cm depth
with 12 cm margin on gross disease. Review of
the literature shows a trend to increased toxicity
(hemoptysis in particular) with increasing dose/
fraction. Administration of sequential/concurrent chemotherapy may also increase the risk.
Accordingly, the American Brachytherapy Society
has published recommended dose and fractionation schedules as described in Table 4 [81].
6.1
Background
LDR interstitial lung brachytherapy has been utilized in the treatment of lung cancer. The experience of Nori and Hilaris from Memorial Sloan
Kettering of iodine-125 (I-125) brachytherapy
implantation in lung cancer patients has been
extensively reported in the past [14, 8284]. In
general, it was used in unresectable patients or in
patients with close/positive margins placed along
the chest wall/pleural surface or for paraspinal
tumors [85]. The outcomes in patients where
225
such invasive brachytherapy techniques have

been used have not materialized into improved
survival; however, they have paved the way for
further applications.
One such patient population where permanent lung brachytherapy has shown a potential
beneficial impact is in high-risk resectable stage
I non-small cell lung cancer patients. High-risk
resectable patients are defined as patients that
cannot tolerate an anatomic lobectomy due to
physiologic, functional, and/or comorbid status
but can tolerate a sublobar resection such as a
wedge resection. High-risk resectable patients
include, but are not limited to, patients with marginal cardiopulmonary reserve (FEV1 50 % of
predicted, DLCO 50 % of predicted), increased
age, pulmonary hypertension, left ventricular dysfunction, elevated pCO2, and increased
Modified Research Council Dyspnea scale [86].
Multiple surgical series of such high-risk patients
that were treated with wedge resection have
shown a significantly worse local failure rate in
the order of 1520 % when compared with lobectomy historical controls which have local failure
rates well under 10 % [8789]. A randomized
trial from the Lung Cancer Study Group confirmed an increased local failure rate in patients
with T1N0 non-small cell lung cancer randomized to lobectomy vs. sublobar resection with no
impact on overall survival [90].
In order to potentially improve local control
in the setting of sublobar resection for these
high-risk resectable patients, radionuclide
impregnated sutures can be placed at the time of
surgery along the sublobar resection staple line.
Iodine-125 is the most commonly utilized isotope in this application. Other isotopes that can
also be used are cesium-131 (Cs-131), palladium-103 (Pd-103), and iridium-192 (Ir-192).
Table 5 summarizes some potential isotopes
with isotope characteristics and commonly prescribed doses.
125-I Technique
7.1
Impregnated Mesh
The I-125 mesh technique has been described in

prior publications [91, 92]. Iodine-125 seeds are
ordered from a supplier and arrive embedded in a
polyglycolic suture attached to a curved needle
on one end. There are ten seeds per suture at 1 cm
spacing. The number of seeds and rows of I-125
suture that are implanted is dependent on the
activity of the sources and the desired prescribed
total dose. Table 6 is an in house reference table
developed at Allegheny General Hospital that
aids in defining the seed spacing based on various
seed activities to give a desired total dose of 100
120 Gy to a 0.5 cm planar depth.
With a sterile technique, a template is drawn
onto the mesh with row spacing defined by the
lookup table. The I-125 suture is then sewn
onto the mesh and secured to each end of the
mesh with staples by the radiation oncologist
(Fig. 5). The impregnated mesh (Fig. 6) is then
delivered intraoperatively to the thoracic surgeon and placed along the sublobar resection
staple line. Figure 7 depicts the wedge resec-
Table 5 Isotope characteristics and commonly prescribed doses for lung brachytherapy
Isotope
Iodine-125
Cesium-131
Palladium-103
Iridium-192
Average energy
(kev)
28
30
20
380
Half-life
(days)
60
9.7
17
74
LDR low-dose rate, HDR high-dose rate
Brachytherapy
technique
LDR mesh
LDR mesh
LDR mesh
HDR remote
afterloading
Prescribed total
dose
100140 Gy
80 Gy
100125 Gy
24.5 Gy (3.5 Gy
twice daily in
seven fractions)
(103)
Prescription depth
(cm)
0.5
0.5
0.5
1.0
P. Renz et al.
226
Table 6 Lookup table for I-125 mesh technique
Treatment area of 4.0 cm 9.0 cm
100 Gy
120 Gy activity/ activity/seed
seed (mCi)
(mCi)
0.37
0.31
0.44
0.37
0.63
0.53
0.74
0.62
Number
of rows
6
5
4
4
Row
spacing
(cm)
0.8
1.0
1.3
1.5
Fig. 7 Intra-operative view of the resection bed and

wedge resection staple line (arrow)
Fig. 5 The I-125 suture is sown onto the mesh by the

radiation oncologist
Fig. 8 Intra-operative view of the resection bed with the

I-125 mesh implant placed over the wedge resection staple line
7.2
Fig. 6 The I-125 mesh implant
tion staple line and Fig. 8 shows the same staple line with I-125 implant placement. In
general, the goal is to place the implant on the
staple line with a 2 cm lateral margin on either
side. The implant can be sutured into place
with 2-0 or 3-0 silk or polyglycolic suture.
When reinflating the lung, the implant should
constantly be visualized to ensure there is no
migration away from the staple line. Premade
radioactive Cs-131 and I-125 mesh implants
are also available and can be ordered directly
from the vendor.
Double-Suture Technique
Iodine-125 seeds embedded in polyglactin 910

suture (Oncura, Princeton, NJ) in strands of ten
seeds are sutured at a 0.5 cm distance on both
sides of the visualized resection margin [93]. A
common seed activity is between 0.7 and
0.8 mCi/seed with prescribed total dose of 125
140 Gy to a 1 cm depth along the central axis or
resection margin [86].
Dosimetry
CT-based implant dosimetry occurs between 3

and 6 weeks postoperatively. A non-contrast chest
CT simulation is performed using 0.3 cm slice
Fig. 9 CT based dosimetry of an I-125 implant with isodose lines (gold line represents the prescibed dose of 120
Gy)
thickness through the lungs. The clinical tumor

volume equals the resection margin or sublobar
staple line. The radioactive seeds are digitized
into the treatment planning system and dose is
calculated based on AAPM TG 43 [26]. Figure 9
is indicative of such a brachytherapy CT plan.
Outcomes
Numerous centers have reported their institutional experience regarding lung brachytherapy
in this clinical scenario [86, 9396]. Table 7
shows a summary of reported series showing a benefit with lung brachytherapy when
compared to historical controls. These series
utilized permanent low-dose rate (LDR) techniques with the exception of one that utilized
a remote afterloading high-dose rate (HDR)
technique [95].
A series from Allegheny General Hospital in
Pittsburgh reported on 145 patients with highrisk stage I NSCLC that underwent sublobar
resection and placement of I-125 mesh brachytherapy intraoperatively along the sublobar resection staple line [94]. The median prescribed total
dose was 120 Gy with a median total number of
seeds implanted of 40. The median total implant
activity was 20.2 mCi (range, 11.129.7).
Postoperative CT scans of the chest revealed no
seed migration. They reported a local failure rate
227
of 4.1 % which compares favorably with local

failure rates of 1520 % in sublobar resection
alone in historical control series [87, 90, 93, 94].
Three- and 5-year overall survivals were 65 %
and 35 %, respectively.
Lee et al. reported their experience on
33 T1-2N0M0 patients with NSCLC that were
not candidates for lobectomy [93]. The doublesuture technique was utilized using I-125 prescribed to a total dose of 125140 Gy. At a
median follow-up of 51 months, there were two
recurrences at the resection margin with a 5-year
survival of 47 % [93]. The authors concluded that
limited resection and brachytherapy is associated
with a relatively low incidence of local recurrence and may prolong survival [93].
Parashar et al. published their institutional retrospective experience using wedge resection and
Cs-131 brachytherapy (either mesh- or doublesuture technique) and compared it to patients
treated with wedge resection alone and stereotactic body radiotherapy [96]. The use of brachytherapy was based on the thoracic surgeons
assessment of whether margins would be close/
positive. Fifty-two patients underwent wedge
resection followed by Cs-131 brachytherapy
application and at a median follow-up of 14
months in the brachytherapy group; local control
was 96.2 % [96].
In light of these multiple single institution series showing a potential local control
benefit, a randomized phase III trial from the
American College of Surgeons Oncology
Group (ACOSOG) was conducted [86]. This
study randomized 224, high-risk operable
stage I non-small cell lung cancer patients
with lesions 3 cm or less to sublobar resection
alone versus sublobar resection plus I-125 lung
brachytherapy (using either the mesh- or double-suture techniques). Local recurrence was
defined as failure at the staple line (local progression), failure within the involved lobe, and/
or failure in the ipsilateral hilar lymph nodes.
At a median follow-up of 4.38 years, there
was no difference in local progression, local
recurrence, or survival between the two arms.
The 3-year overall survival was 71 % in each
arm. Brachytherapy was not associated with
108
T1-2 (T3: 1
patient)
T stage
T1-2
T1-2
T1-2
T1-4 N0-2
WR wedge resection, Seg segmentectomy
ACOSOG Z4032
brachytherapy arm
[86]
Colonias et al. [94]

Lee et al. [93]
Parashar et al. [96]
McKenna et al. [95]
N
145
33
52
48
WR/Seg
Type of
surgery
WR/Seg
WR/Seg
WR
WR
Table 7 Various series of sublobar resection and brachytherapy
I-125
Isotope
I-125
I-125
Cs-131
Ir-192
Brachytherapy
technique
LDR mesh
LDR double suture
LDR mesh
HDR remote
afterloading
LDR mesh or
double suture
100
Prescribed dose
(Gy)
Median 120
125140
80
24.5
4.38 years
Median follow-up
(months)
38.3
51
14
13.5 (mean)
7.7 % (in both

arms)
Local
recurrence
4.1 %
6.1 %
3.8 %
6.25 %
55.6 %
5-year overall
survival
35 %
47 %
100 %
228
P. Renz et al.
increased perioperative pulmonary adverse

events and at 3 months did not affect pulmonary
function [97]. Furthermore, there was no difference in quality of life measures or dyspnea
score between the two arms [98].
Even though the ACOSOG Z4032 trial was an
overall negative brachytherapy study, the authors
concluded that certain situations may still exist to
warrant the use of brachytherapy to improve local
control. These scenarios revolve around margin
status or as the authors state in patients with
potentially compromised margins and include
positive cytology at the staple line, margins of
less than 1 cm, margin to tumor ratio <1, tumor
size >2 cm, and wedge resection (vs. segmentectomy) [86]. Although subset analysis revealed no
statistically significant benefit with brachytherapy in these settings, further study of such compromised margin patients with a larger sample
size may be warranted.
10
Other Potential Indications
Mutyala et al. reported on a series of 59 patients

with various thoracic malignancies (including nonsmall cell lung cancer, sarcoma, giant cell tumor,
and carcinoid) treated with primary surgery with
the use of I-125 mesh brachytherapy as an adjunct
if the patient was at risk of close or positive margins [99]. The prescribed dose of the implants
ranged between 100 and 150 Gy to a 0.5 cm depth
for radiation nave patients and 5070 Gy for
patients having received prior radiation [99]. At a
median follow-up of 17 months, 1- and 2-year local
control was 80.1 % and 67.4 %, respectively [99].
The authors concluded that brachytherapy is associated with low toxicity and should be further studied in incompletely resected patients.
11
Brachytherapy
in Esophageal Cancer
11.1
Incidence/Epidemiology
The American Cancer Society estimates 16,900

cases of esophageal cancer will be diagnosed in
229
the United States in 2015. It will account for an

estimated 15,590 cancer-related deaths in the
United States in 2015 [1]. Worldwide, esophageal cancer accounted for over 482,000 cases and
over 406,000 cancer-related deaths in 2008 [100].
Squamous cell carcinoma and adenocarcinoma
of the esophagus account for the overwhelming
majority of esophageal cancers. Historically, squamous cell carcinoma was the predominant type of
esophageal cancer. The incidence of squamous
cell carcinoma in the United States has been
declining. The incidence of adenocarcinoma, however, has increased dramatically, now accounting
for over 60 % of esophageal cancers. Worldwide,
squamous cell carcinoma remains more common.
Men are affected much more commonly than
women. Squamous cell carcinoma of the esophagus is more common in African-American men,
while adenocarcinoma of the esophagus is more
common in Caucasian men [101].
The main risk factors for the development of
squamous cell carcinoma of the esophagus are
tobacco and alcohol use. Lower socioeconomic
status is also associated with the development
of squamous cell carcinoma of the esophagus.
The main risk factor for the development of
adenocarcinoma of the esophagus is the presence of Barretts esophagus with intestinal
metaplasia, a consequence of gastroesophageal
reflux disease. Additionally, obesity and
tobacco use are associated with adenocarcinoma of the esophagus.
11.2
Diagnosis and Staging
The majority of patients with esophageal cancer

are symptomatic. Dysphagia and weight loss are
common. Typically, diagnosis is established with
upper endoscopy and biopsies. Surveillance
endoscopy may identify early-stage esophageal
cancer in the asymptomatic patient with Barretts
esophagus. A barium esophagram may also help
diagnose esophageal cancer.
Staging of esophageal cancer is dependent on
the tumor-node-metastasis classification. Squamous
cell carcinoma and adenocarcinoma of the esophagus are considered separately [102]. Tumor status
P. Renz et al.
230
relates to the depth of tumor involvement of the

esophageal wall, while nodal status relates to the
number of regional lymph nodes. Metastasis relates
to the presence of distant disease.
CT and PET scans are routinely obtained, primarily to rule out distant disease. CT and PET
scan are inadequate in regard to accurate evaluation of the tumor involvement of the esophageal
wall and periesophageal lymphadenopathy.
Endoscopic ultrasound provides a much better
assessment of local tumor extent and periesophageal nodal involvement. Laparoscopy, thoracoscopy, and bronchoscopy are adjunct staging
modalities that may be considered in specific
cases, based on imaging and tumor location.
11.3
Survival
Survival correlates with stage of disease in

patients with localized, potentially resectable
disease. Infrequently, patients with cancer limited
to the mucosa or submucosa may be identified.
These patients represent the best chance for longterm survival and possible cure.
Unfortunately, the majority of patients present
with locally advanced or metastatic disease.
Long-term survival is poor in patients with
locally advanced disease, with cure rates of
approximately 15 %, following multimodality
therapy. Long-term survival is highly unlikely in
patients with metastatic disease.
12
Treatment Overview
For patients with early-stage disease, limited to

the mucosa (T1aN0), endoscopic mucosal resection may be curative. Pathologic review of the
lesion is critical. Involvement of the submucosa
(T1bN0) generally mandates esophageal resection, due to potential lymphatic spread into the
rich submucosal lymphatic network. Patients with
involvement of the muscularis propria (T2N0)
may be considered for esophagectomy as the initial treatment strategy.
For medically operable patients with locally
advanced, potentially resectable disease (typi-
cally T2 or greater or patients with nodal disease), neoadjuvant (induction) chemoradiotherapy

or chemotherapy is offered, followed by restaging and possible resection. Induction chemoradiation followed by resection demonstrates
improved survival over surgery alone in multiple
reports [103105].
In the medically inoperable patient or in the
patient with squamous cell carcinoma of the
proximal esophagus, definitive chemoradiation
may be considered. Resection may not be possible due to local involvement or proximal extent
of tumor in patients with squamous cell carcinoma of the upper third of the esophagus.
For patients with resectable tumors of the
mid-thoracic esophagus, total esophagectomy
with cervical anastomosis is required. For
patients with resectable tumors of the distal
esophagus or gastroesophageal junction,
esophagectomy with intrathoracic anastomosis
or total esophagectomy with cervical anastomosis
can be performed. Reconstruction can be
accomplished with creation of a gastric conduit
or a colonic interposition.
Various surgical approaches can be utilized,
including a three-field approach with cervical, thoracic, and abdominal exposure, a trans-hiatal
approach (cervical and abdominal exposure), or an
Ivor-Lewis approach (abdominal and thoracic
exposure). Minimally invasive techniques can be
incorporated into any of these approaches, during
the abdominal and/or thoracic portions of the
procedure.
In addition to esophageal resection and restoration of gastrointestinal continuity, the procedure may include a concomitant gastric drainage
procedure (botulinus toxin injection of the pylorus, pyloromyotomy, or pyloroplasty) and insertion of a jejunal feeding tube.
In patients with metastatic disease (stage IV)
and patients who are not candidates for surgery
or systemic therapy, palliation of esophageal cancer can be considered. This may involve endoluminal therapies, including dilation, stenting,
cryotherapy, and photodynamic therapy, and
high-dose rate brachytherapy can be considered
in the management of malignant stricture,
obstruction from tumor, or bleeding.
231
13
Esophageal Brachytherapy
13.3
13.1
Overview
The technique for endoluminal HDR esophageal

brachytherapy requires an esophagogastroduodenoscopy (EGD) with placement of a brachytherapy catheter. At the time of EGD, the distance
of the endoluminal lesion from the incisors and
length of the lesion should be recorded. The
brachytherapy catheter is then placed beyond the
lesion, and the scope is removed, while fluoroscopy is performed to make sure that the brachytherapy catheter remains in place. The catheter
should be placed at least 34 cm past the lesion to
insure treating the usual margin of 12 cm proximal and distal to the visible mucosal disease. A
metallic clip can also be placed submucosally at
the proximal edge of the lesion so that the lesion
can be readily identified at the time of CT simulation during target delineation and for treatment
planning [116]. Once the patient recovers from
anesthesia, he or she is transported to the radiation oncology department for CT simulation with
a similar process for simulation, planning, and
treatment as stated in the endobronchial brachytherapy section of this chapter.
Esophageal brachytherapy can be performed

using high-dose rate or low-dose rate techniques.
Remote afterloading HDR has the advantage of
being an outpatient procedure and limits radiation exposure to health-care workers. Studies
comparing LDR with HDR have shown equivalent outcomes in terms of palliation of dysphagia
[106] and locoregional control and survival
[107]. The most commonly used radioisotope for esophageal HDR is iridium-192.
Californium-252, a neutron-emitting isotope,
can also be utilized and dose is specified in
Gy-equivalent [108].
13.2
Indications
High-dose rate esophageal brachytherapy is

used in the palliation of symptoms caused by
endoluminal disease, most commonly dysphagia. Other less common uses are in the definitive setting as a boost combined with external
beam radiation or as sole therapy in superficial
cancers. The American Brachytherapy Society
has published consensus guidelines for esophageal brachytherapy [109]. Good candidates for
brachytherapy include patients with tumors
<10 cm in length and confined to the esophageal
wall, thoracic location, and patients without
regional nodal involvement [109111]. Patients
with cervical esophageal tumors and/or fistulas
should not undergo brachytherapy as these conditions are associated with significant toxicity
[109, 112]. Likewise, concurrent chemotherapy
is associated with increased treatment-related
toxicity including fistula formation [109, 113]
and esophageal stricture/ulcer formation [114,
115]. The ABS does not recommend concurrent chemotherapy and brachytherapy [109].
Furthermore, patients with tumor extending
into the gastroesophageal junction and proximal stomach are not optimal candidates for
brachytherapy as target coverage may not be
optimal [109].
13.4
HDR Technique
Denitive Therapy: Supercial

Cancer
The standard definitive treatment for esophageal

cancer depends on the stage and extent of disease
along with the patients comorbidities,
performance status, and their preference. To
properly stage these patients, endoluminal
ultrasound is required to evaluate the depth of
invasion of the primary tumor and to evaluate for
regional nodal metastasis. For early mucosal disease, local measures such as mucosal resections
are warranted [117119]. In the event that such
interventions cannot be performed, brachytherapy with or without external beam radiation can
be used [120, 121]. External beam radiation combined with brachytherapy is recommended when
there is significant risk of nodal involvement.
Pasquier et al. reported on 66 patients with
superficial (Tis or T1) esophageal cancers that
were not surgical candidates or refused surgery
P. Renz et al.
232
[121]. These patients received external beam

radiation and HDR brachytherapy without chemotherapy. The most common treatment regimen was external beam radiation to a total dose
of 60 Gy combined with an HDR boost of
14 Gy in two fractions, prescribed to a 0.5 cm
depth. The median survival was 3.8 years with
a 6 % rate of severe toxicity (primarily esophageal stenosis). The authors concluded that this
regimen was tolerable and an option for inoperable patients with superficial esophageal
cancer [121].
Ishikawa et al. reported on 59 patients with
submucosal esophageal cancer that were treated
with external beam radiation therapy. Thirty-six
had an esophageal brachytherapy boost using
LDR cesium-37 until 1997 and then HDR
iridium-192. Brachytherapy was performed after
external beam was complete and chemotherapy
was not given. Overall locoregional control was
75 % at 5 years. Five-year cause-specific survival
was better in the patients that received a
brachytherapy boost (86 % vs. 62 %; p = 0.04)
[120]. The authors concluded that external beam
radiation followed by brachytherapy was superior
to external beam alone.
13.5
Denitive Therapy: Advanced

Disease
In more advanced disease (T2 disease or greater

or nodal involvement), the standard therapy is
esophagectomy vs. induction chemoradiation
then resection vs. definitive chemoradiation
[104, 105, 122]. Brachytherapy can be added
to external beam radiation as a boost modality
in advanced disease but may be associated with
significant toxicity and is not considered standard therapy in the United States. Reports from
two randomized studies that compared external
beam radiation alone with external beam radiation combined with esophageal brachytherapy
showed better survival and local control as well
as increased toxicity in the combined treatment
arm [123, 124]. Numerous other series have been
published using brachytherapy in the definitive setting with conflicting results [108, 113,
125127]. Many of these studies did not utilize

concurrent chemotherapy which remains the
standard of care.
Muijs et al. reported on 62 patients with
esophageal cancer treated with external beam
radiation to a total dose of 60 Gy combined with
an LDR or HDR boost [126]. About one-third of
these patients had nodal disease and almost half
had T34 disease. Patients received a 12 Gy
boost in two fractions with either LDR
(cesium-134) or HDR (iridium-192). No patient
received chemotherapy. There was a 16 % rate of
grade III toxicity including esophageal ulceration,
stricture, radiation pneumonitis, fistula, and
bleeding. The authors concluded that due to
complications, the addition of brachytherapy was
not recommended [126].
The Radiation Therapy Oncology Group
(RTOG) performed a phase I/II study (RTOG
9207) utilizing concurrent cisplatin/5-FU
chemotherapy with external beam radiation
combined with HDR brachytherapy in esophageal cancer patients [113]. HDR brachytherapy
was initially performed in three fractions of 5 Gy/
fraction prescribed to a 1 cm depth from midsource on weeks 8, 9, and 10 but due to toxicity
was reduced to only two fractions. Low-dose rate
brachytherapy was also allowed but had poor
accrual. The study reported a 12 % incidence of
treatment-related fistula within 7 months of
therapy and a 10 % incidence of treatment-related
death [113].
13.6
Palliation
Numerous series have reported their experience

on the effective use of brachytherapy in the palliative setting with most reporting on dysphagia
[109, 116, 128131]. In the palliative setting, the
ABS recommends HDR total doses of 1520 Gy
in 24 fractions prescribed to a 1 cm depth in
weekly fractions (LDR dose of 2540 Gy at
0.41 Gy/h) [109]. Brachytherapy can also be
combined with palliative external beam radiation.
In this setting the ABS recommends a lower
HDR dose of 1014 Gy in 12 weekly fractions
(LDR dose of 2025 Gy at 0.41 Gy/h) [109].
Fabrini et al. reported their single institution

experience of 104 patients that received
brachytherapy as part of their treatment regimen
[116]. The report included definitively and palliatively treated patients. The HDR dosing regimen
for the palliative patients was 15 Gy in 3 weekly
fractions. The authors reported an 84.6 % rate of
improvement of dysphagia and a median dysphagia-free interval of 17.5 months. Lymph node
involvement was a predictor for overall survival
and dysphagia. Three patients developed esophagotracheal fistulas [116].
Rupinski et al. reported on 93 patients with
dysphagia due to malignant esophageal disease
randomized to argon plasma coagulation laser
(APC) alone vs. APC combined with brachytherapy vs. APC combined with photodynamic
therapy (PDT) [130]. There was no survival difference between the three treatment arms. The
two combined treatment arms had better palliation of dysphagia than the APC alone group.
There was no significant difference in palliation
of dysphagia between the two combined groups.
The patients in the HDR + APC group, however,
had fewer complications and better quality of life
than the PDT + APC patients [130].
Palliative esophageal brachytherapy can also
be combined with self-expanding metal stent
(SEMS) placement [128]. Amdal et al. reported a
study of 41 patients with malignant esophageal
dysphagia randomized to SEMS + brachytherapy
vs. brachytherapy alone. Both arms received 8 Gy
in three fractions. There was improved dysphagia
relief at 3-week follow-up in the combined treatment arm, but at 7 weeks, dysphagia relief was
similar between the two arms. Four patients in the
combined arm experienced complications requiring a prolonged hospitalization (two had aspiration pneumonia, one aspiration pneumonia and
bleeding, and one stent migration) with no
reported fistulas or perforations [128]. Based on
this study, combining SEMS with brachytherapy
can be performed but may be associated with
increased risks when compared to brachytherapy
alone due to risk of stent migration and other
complications. An alternative to SEMS placement
may be APC combined with brachytherapy [130].
Esophageal dilatation can also be performed but
233
should not be performed on the day of brachytherapy as there may be an association with fistula
formation [113].
Conclusions
HDR brachytherapy is primarily used in the

palliative setting with common dosing schedules of 1520 Gy in 24 fractions as monotherapy or 1014 Gy in 12 fractions when
combined with external beam radiation [109].
In the definitive setting, brachytherapy is not
considered standard therapy. In early disease,
surgical resection is usually performed and in
more advanced disease, various regimens can
be performed including chemoradiation or trimodality therapy (depending on the extent of
disease). In the event that surgery and chemotherapy cannot be performed, external beam
radiation with or without brachytherapy can
be considered. The ABS recommends
4550 Gy of external beam radiation followed
by either HDR to a total dose of 10 Gy in 2
weekly fractions or LDR to a total dose of
20 Gy at 0.41 Gy/h (23 weeks after completion of external beam radiation) with a 23week interval between chemotherapy and
brachytherapy. Concurrent chemotherapy is
not recommended due to risk of severe toxicity including fistula formation.
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Image-Guided High-Dose Rate

Brachytherapy in the Treatment
of Liver Cancer
Nikolaos Tselis, Konrad Mohnike, and Jens Ricke
Abstract
High-dose rate brachytherapy for primary and secondary liver malignancies is an innovative radio-oncological modality enjoying rapid acceptance and adoption in the field of interventional oncology. It is a safe and
effective treatment most useful in the salvage situation in patients with
large hepatic tumors or an intermediate number of lesions unsuitable for
thermal ablation or stereotactic external radiotherapy. In this chapter the
radiobiological and technical aspects of CT-guided brachytherapy for the
treatment of liver cancers are discussed. Clinical toxicity and efficacy outcomes after this technique are described including a comprehensive data
review.
Introduction
According to estimations of the World Health

Organization, liver cancer presents the fifth most
common cancer type among men and the seventh
among women accounting for approximately
746,000 deaths worldwide in 2012 [1]. Against
N. Tselis, MD, PhD (*)

and Interdisciplinary Oncology,
K. Mohnike, MD J. Ricke, MD
Department of Radiology and Nuclear Medicine,
Otto-von-Guericke-University Magdeburg,
Magdeburg, Germany
this background, primary hepatocellular carcinoma (HCC) is increasing in incidence and it is

now the sixth most common malignancy [2].
Because of its high fatality rate with the mortality
to incidence ratio being almost united [3, 4], treatment improvements are widely sought after with
complete surgical resection remaining the gold
standard for the cure of primary hepatic malignancies [5]. Similarly, it is widely accepted in colorectal cancer that surgical treatment of liver metastases
is associated with a significant chance of cure [6].
In addition, emerging data suggest benefits of therapeutic hepatic metastasectomy also for other primary sites, such as breast cancer [7]. Unfortunately,
many patients with malignant hepatic tumors are
not candidates for resection due to the extent of
their underlying liver disease or the burden of
tumor present in the liver. Although recent

DOI 10.1007/978-3-319-26791-3_13
239
N. Tselis et al.
240
advances in patient selection and surgical technique have resulted in low mortality after liver
resection [8], the mortality rate for extended hepatectomy is up to 5 % with a morbidity rate of 50 %
[9]. For those patients, hyperthermal techniques
such as radiofrequency ablation (RFA) and laserinduced thermotherapy have been reported to be
alternative local treatment choices [1017].
However, one of the major challenges with these
percutaneous approaches is residual cancer tissue
after incomplete treatment of larger tumors or
lesions with proximity to voluminous vascular
structures. Factors impairing the therapeutic ratio
are tumor size, with an accepted upper size limit of
34 cm for optimal treatment [1820], and the
heat-sink effect, hampering effective cytoreduction in perivascular lesions [19, 2123]. In fact, the
likelihood of recurrence increases rapidly beyond
a threshold of 3-cm lesion diameter [24, 25] with
tumor location next to the liver hilum being an
additional contraindication because of the risk of
bile duct injury. These limitations of hyperthermal
techniques and the need for nonsurgical local therapies were the primary motivation that led to the
implementation of computed tomography (CT)guided interstitial (IRT) high-dose rate (HDR)
brachytherapy (BRT) in the treatment of hepatic
tumors. It enables the conformal administration of
very large radiation doses to a circumscribed volume, allowing not only precisely predictable
energy deposition but complete tumor sterilization
regardless of tissue inhomogeneity, thermal conductivity, or tumor perfusion. It has proven safe
and effective in the treatment of primary and secondary liver malignancies with no known restriction concerning the location or maximum lesion
size for successful radioablation [2123, 2636].
Treatment Procedure
2.1
Implantation Techniques
Interstitial catheter implantation is usually performed under local or general anesthesia with
various catheter placement patterns being
described. Extensive experience exists for the

technique of CT-guided implantation [21, 23,
28, 35]; however, MRI-based approaches have
also been reported in the literature [3739].
For CT-guided implantation, two similar
approaches have been described with one incorporating the Seldinger catheter replacement
technique [22] and one without this interventional radiology procedure step [34]. In both
experiences the clinical workflow includes the
creation of virtual volumes prior to implantation
for treatment preplanning in order to estimate
the number and alignment of catheters required
to be placed percutaneously. After completion
of the virtual preplanning, a fluoroscopy CT
scan is used to aid in positioning of the catheters. After puncture of the hepatic lesion with a
coaxial needle, a very stiff angiography guide
wire is introduced. The needle is then exchanged
over the wire against an angiography sheath of
6-F diameter. Sheaths with hydrophilic coating
are favorable because they cause less pain during insertion through the liver capsule (e.g.,
Radifocus, Terumo; Tokyo, Japan). After
removal of the guide wire, a BRT catheter can
be placed in the sheath. Closure of the puncture
tracts at the end of the entire procedure including irradiation is achieved by filling the puncture tract with Gelfoam during sheath removal.
Similar to the Seldinger-based technique
described by Ricke et al. [22], the procedure
without catheter replacement employs also CT
guidance in appropriate patient position [34].
Round-tip plastic catheters of 6-F diameter and
200-mm length (OncoSmart ProGuide Round
Needle: Nucletron B.V., Veenendaal, The
Netherlands) are implanted directly into the
hepatic lesion through skin incision using a
rigid tungsten alloy obturator (Fig. 1). In general, number, geometrical alignment, and distance between the catheters are dependent on
the size, shape, and location of the hepatic
lesion. Practically, one catheter is inserted per
12-cm tumor diameter.
In MRI-based implantation [22], catheter
placement is also performed percutaneously
Image-Guided High-Dose Rate Brachytherapy in the Treatment of Liver Cancer
including a preplanning step based on

three-dimensional (3D) image volumes acquired
by pre-interventional MRI sequences. The number, distribution, and distance between the catheters are determined by preplanning which
calculates the peripheral catheter arrangement
241
with arbitrary optimization for target coverage.

Catheter implantation with control of maximum
insertion depth and positional verification of the
implanted catheters is performed by interactive
MRI scanning employing again the catheter
replacement technique (Fig. 2).
Fig. 1 Fifty-three-year-old female with a metachronous

liver metastasis from breast cancer. The patient received
single-fractionated IRT BRT after failure of multiple systemic chemotherapies. The HDR BRT was delivered in a
single fraction of 15.0 Gy. (a) 3D implant reconstruction
for CT-based treatment planning showing the irregularly
shaped liver tumor (red volume) with the five implanted
catheters. The volumetrically calculated lesion size was
261.8 cm3. (b) Axial CT/MRI image fusion illustrating
the dose distribution of the implant based on a 3D registration of the post-implant CT data set with a preinterventional contrast-enhanced MRI data set. The color
gradation represents: red = 300 %, isodose = 45.0 Gy;
blue = 200 %, isodose = 30.0 Gy; yellow = 150 %, iso-
dose = 22.5 Gy; orange = 100 %, isodose = 15.0 Gy; and

green = 50 %, isodose = 7.5 Gy. One of the five implanted
catheters is identifiable by radiopaque markers along its
axis. Intended minimal tumor dose per fraction is the reference dose of 15.0 Gy, specified as the 100 % isodose.
The central part of the tumor is covered at least by the
300 % isodose and receives total doses clearly above
45 Gy within a single treatment fraction. (c) Preinterventional T2 MRI imaging showing the extensive
liver metastasis. (d) T2 MRI imaging at 3 weeks after
BRT showing early response of the hepatic metastasis
expressed as partial remission with discrete perilesional
edema
N. Tselis et al.
242
Fig. 1 (continued)
2.2
Imaging for Treatment

Planning
After completion of the catheter implantation

procedure, an adequate image series is acquired
for the process of anatomy-oriented treatment
planning. Treatment planning after CT-guided
implantation is most commonly performed using
CT imaging [21, 23, 26, 35]. In addition, MRIbased treatment planning (with or without MRIguided implantation) has also been implemented
in clinical practice [3739]. In both cases a
breath-hold contrast-enhanced image acquisition
with slice thickness of 0.5 cm is recommended

to ensure accurate anatomy delineation and
reproducible catheter reconstruction as part of
3D treatment planning [39, 40]. For a more
accurate delineation of the target volume, MRI
and CT co-registration can be considered.
Alternatively, only MRI can be used where both
T1- and T2-weighted images should be
considered for an optimal visualization of
anatomy and catheter position [37]. Irrespective
of the imaging modality for interventional
guidance or treatment planning, HDR irradiation
is performed using a remote afterloading system.
A typical HDR afterloading system features a
192-iridium (192Ir) source of a maximum 10 Ci.

The duration of the irradiation ranges from 20 to
40 min depending on the size of the target, the
accuracy of the catheter array inserted, and the
respective age of the 192Ir source.
2.3
Anatomy Denition
Even though the concepts of target volumes and

organs at risk (OAR) were formalized by ICRU
Report 50 [41], BRT practitioners have reported
different target and treatment philosophies in the
literature [23, 35, 38, 42, 43]. In order to develop
Fig. 2 Sixty-two-year-old female with synchronous liver

metastases from colorectal cancer. The patient received
single-fractionated IRT BRT after failure of multiple systemic chemotherapies including FOLFOX, FOLFIRI, and
irinotecan/Erbitux. The HDR BRT was delivered in single
fractions per tumor between 19.4 and 22.8 Gy covering in
total five metastases in the right liver lobe in two treatment
sessions at an interval of 2 weeks. The left liver lobe was
aplastic. (a) Pre-interventional contrast-enhanced T1 MRI
imaging showing three of the five lesions. (b) 3D implant
reconstruction for MRI-based treatment planning showing three of the five metastases with the implanted catheters and the isodose lines. The volumetrically calculated
lesion size was between 2.1 and 9.9 cm3. The respective
243
consistency in target and volume definition for

liver BRT, the following may be considered for
treatment planning independent of the acquired
imaging modality:
(a) In image-guided IRT BRT, the implanted
catheters are positioned and fixed inside the
target volume. Hence, organ motion is not a
limiting factor and the clinical target volume
(CTV) and planning target volume (PTV) are
theoretically not different. Therefore,
CTV = PTV with CTV being defined as the
gross tumor volume as outlined in contrastenhanced CT/MRI.
color gradation scale for the isodose lines is explained on

the left. The tumor volume is delineated in red. Intended
minimal tumor dose per fraction is the reference dose of
20.0 Gy, specified as the 100 % isodose. (c) Contrastenhanced T1 MRI imaging at 12 weeks after BRT shows
a sharply defined scar at the place of the former metastases. The patient developed limited and sequential progression with new metastases at different time points during
follow-up in the liver and lung, all of them ablated with
either HDR BRT or radiofrequency ablation. Thirty-six
months after the first BRT and 48 months after initial
diagnosis, the patient is still alive and doing well
N. Tselis et al.
244
Fig. 2 (continued)
(b) The dominant organ at risk (OAR) is the liver

itself. Further OARs to be considered at the
time of 3D treatment planning include the
stomach and the duodenum and in patients
with direct tumor contact, the biliary tree
bifurcation.
2.4
Dose Prescription
Initial studies of intraoperative BRT for liver

cancers suggested that tumor enclosing isodoses
of 1530 Gy should be used irrespective of the
tumor histology [44, 45]. However, advanced
CT-guided HDR BRT has provided more accurate

data on what dose levels are necessary to achieve
durable tumor control in various tumor types. In
a prospective randomized trial of 73 patients with
199 colorectal liver metastases, minimal dose
levels enclosing the PTV of 15, 20, and 25 Gy
were tested [31]. A dose dependency for local
tumor control was shown with no local recurrences observed if the minimum dose to the target (D100) exceeded 23 Gy. In another prospective
trial evaluating the effect of CT-guided HDR
BRT in HCC, a minimal dose of 15 Gy was prescribed, with local control after 1 year of >90 %
[30]. There is also evidence that breast cancer
metastases may be treated successfully with a
15 Gy covering isodose whereas other tumor
subtypes such as colorectal carcinoma likely
require a minimum dose >18 Gy [27, 36, 46]. In
spite of the high sensitivity of the minimum dose
(D100) to small delineation inaccuracies in the
PTV, there is also literature referring to planned
dose as the achieved D90-values for the PTV [34,
35]. In this methodology the dose distribution is
normalized to the calculated mean dose value on
the PTV surface to be 100 % and the reference
dose specified at the 100 % isodose surface.
Those values are more stable regarding delineation inaccuracies and resolution of the calculation grid or the number of sample points than the
minimum peripheral dose values. However, no
consensus on the required methodology for dose
prescription in HDR liver BRT exists. The foregoing notwithstanding in large tumors (>8 cm)
excessive irradiation time and unpredictable risks
can hamper the delivery of >20 Gy in a single
fraction. This problem may be overcome by
treating large tumor volumes in multiple sessions.
As a rule of thumb, liver tumors more than 8 cm
in diameter should be treated in two or more
implants or with fractionated single-implant BRT
schemes. In addition, to prevent loss of local
tumor control by continuous growth of
micrometastases after single-fraction irradiation
of colorectal liver metastases and HCC, a dose of
at least 15.4 Gy at a distance of 0.21 cm to the
gross tumor margin has been recommended [47].
For the protection of OARs, a maximum dose
exposure of 5 Gy to not more than two-thirds of
245
the liver is recommended [22, 35, 48] with the

12-week threshold dose for hepatocyte function
being estimated at approximately 14 Gy for
500 cm3, approximately 16 Gy for 100 cm3, and
approximately 18 Gy for 10 cm3 of irradiated
liver volume [48]. With regard to stomach and
duodenum, a threshold dose D0.1 cm3 of 11 Gy for
general gastric toxicity and 15.5 Gy for gastric
ulceration has been found [49]. A gastric prophylaxis (pantoprazol 1 40 mg/day for 3 months
and magaldrate H2O) should be prescribed if the
gastric or duodenal mucosa is calculated to
receive more than 10 Gy per 1 cm3 of organ wall.
In addition, the maximum dose to the organ wall
should be <14 Gy/1 cm3. In patients with tumor
in direct contact with the biliary tree bifurcation,
a clinically relevant stenosis of the bile duct is
rarely seen, and steroid prophylaxis to reduce the
risk of radiation-induced edema and subsequent
bile duct obstruction is therefore not generally
recommended. However, in studies of
intraoperative and CT-guided HDR BRT, doses
of 20 Gy have been prescribed to the hepatic
bifurcation without evident complications [22,
26, 35, 44, 50]. For verification of treatment
delivery in the case of multifractionated implants,
repeat CT scans may be obtained before each
treatment fraction for fusion with the initial
treatment planning image set. With this
procedure, the position of every catheter can be
verified in comparison to the initial 3D treatment
plan [35].
Radiobiological and Physical

Considerations
Radiobiological research demonstrates that the

probabilities of acute and late radiation reactions
vary between normal tissues and tumors and
between different radiotherapy (RT) dosefractionation schedules. More precisely,
radiation-induced cell death has been modeled
according to the linear-quadratic (LQ) model
which postulates that multiple radio-induced
lesions interact in the cell to trigger cell killing
with the / ratio, a means of expressing the
sensitivity of a particular tissue to altered fraction
246
size, being used to estimate the impact of a given

schedule on tumor control and toxicity [51]. For
RT of the liver, a clear dose-response relationship
has been reported with the delivery of higher
doses, resulting in improved clinical outcomes
[52]. However, there is an increasing risk of
radiation-induced liver disease (RILD) when the
whole organ is exposed to even moderate doses
with an estimated TD5/5 of 30 Gy for the whole
liver [53], while one-third to two-thirds of the
organ tolerates doses of 35 Gy to 50 Gy,
respectively [54]. Notwithstanding, according to
the LQ model, escalated biologically effective
doses through high-dose fractions are needed to
enhance hepatic tumor cell death [55, 56]. Not
least for this reason, total liver external beam
radiotherapy (EBRT) plays a very limited role in
the treatment of intrahepatic tumors, whereas
focal liver irradiation by hypofractionated
stereotactic body radiation therapy (SBRT) is
becoming more widely used [5759].
Nevertheless, the rapid clinical implementation
of SBRT must not allow us to overlook the fact
that the development of SBRT is based on the
principles of HDR BRT, aiming to reduce the
volume of normal tissue exposed to therapeutic
doses while allowing for biologic dose escalation
through larger fractional dose delivery for hepatic
lesions predominantly less than 4 cm [57, 59
62]. Compared to SBRT, HDR BRT enables the
superior partitioning of radiation between tumor
and healthy organs by generating unlimited
radiation source positions and source dwell times
using image-based treatment planning with
anatomy-oriented dose optimization [40, 63]. It
surpasses the intrinsic capability of SBRT to
perform simultaneous intratumoral dose boosting
while providing greater dose heterogeneity with
higher average doses and a more rapid dose
falloff due to the inverse-square law [64, 65].
This can be illustrated by the following example
as a case in point: If a BRT catheter is positioned
under image guidance in an assumed metastatic
liver lesion of 4-cm extension, a dose of 20 Gy is
typically prescribed enclosing the PTV. For the
inner sphere of a 3.6-cm diameter within the
4-cm tumor, the dose will be > 25 Gy, and for
the 3.2-cm sphere, far more than 30 Gy will be
N. Tselis et al.
delivered. This dose enhancement in most parts

of the target volume is beneficial in light of the
proven dose-response relationship for metastatic
lesions from 15 to 25 Gy [31]. Accordingly,
estimations based on the LQ model confirm that
approximately 20 Gy might be sufficient for a
tumor nodule with a radiosensitivity of
0.3 Gy1 and / 10 Gy [66]. However, the
control dose increases toward 40 Gy for less sensitive tumor cell populations with 0.1 Gy1
and / 10 Gy [66]. This is particularly relevant
assuming that radioresistant clonogenic tumor
cells are considered to reside in central hypoxic
tumor parts [67]. The dose escalation within this
volume is inherently improved with HDR BRT
since the dose gradient from the enclosing
radioablative 20-Gy isodose to the periphery is
steeper than for any EBRT technique, and
considerably less liver tissue is exposed to doses
above tolerance. Assuming a TD5/5 of
conventionally fractionated 30 Gy for the whole
liver [53], a single HDR dose of 10 Gy is biologically equivalent for / 2 Gy [68]. In our example, however, the prescribed reference dose
declines from 20 to 10 Gy in a short distance
from 2.0 to 2.8 cm (the dose is halved along
0.8 cm assuming the inverse-square law
dependency). A 0.8-cm shell of liver tissue
around the tumor of 4 cm is exposed to a
potentially harmful dose, > 10 Gy, which, however, has only a limited volume of 60 cm3. This
is much smaller than the volume required to be
irradiated with EBRT because of the dose falloff.
In addition, for small volumes of liver tissue irradiated with associated steep dose gradients, there
is a greater volume of spared liver that may
regenerate in response to small-volume irradiation injury, likely increasing the overall tolerance
of the liver to radiation. This volume effect has
been confirmed in studies of HDR BRT for small
liver volumes [49, 68, 69].
Next to temporary HDR BRT, permanent
LDR BRT has also been described for the
treatment of liver malignancies [42, 43, 70, 71].
In comparison to LDR, however, 3D HDR
dosimetry is high density because of a vast
array of HDR dwell positions (with variable
dwell times) as permanent seeds in LDR liver
implants. The prospective nature of HDR dosimetry ensures excellent target coverage without
dosimetric changes caused by source migration
and tissue deformity which can occur with seed
implantation.
Clinical Data
A large amount of data is available on local tumor

control (LC) after CT-guided HDR BRT with
consistent and reproducible 1-year LC rates
247
reported for patients with primary (8196 %) and

metastatic liver tumors (73100 %) [2123, 26
33, 35, 36, 46, 66, 7275] (Table 1). Furthermore,
a growing body of literature corroborates
CT-guided HDR BRT as a safe and effective
modality for the radioablation of especially larger
tumors. Collettini et al. [26] reported on 35
lesions ranging from 5 to 12 cm (mean 7.1 cm) in
35 patients with unresectable HCC. Treatment
consisted of single-fraction CT-guided 192Ir HDR
BRT of 1525 Gy with a mean treatment dose of
15.8 Gy. Local control was 96 % at 12 months
Table 1 Literature results of CT-guided interstitial HDR brachytherapy for primary and metastatic liver malignancies
Author
Schnapauff et al. [32]
n
15
Tumor entity
Primary
Mohnike et al. [30]
83
Primary
Collettini et al. [26]
35
Primary
Denecke et al. [75]
12
Primary
98
Primary
Metastases
HDR dose
Median 20 Gy
(1520)
Median 15 Gy
(1225)
Median 15 Gy
(1520)
Minimal
1520 Gy
Mean minimum
16.51 Gy
Median 15 Gy
Tumor size
Median 61 cm3
(2.1257)
Median 3.4 cm
(115)
Mean 7.1 cm
(512)
Mean 3.6 cm
Geisel et al. [29]
Metastases
Median 20 Gy
80
Metastases
Ricke et al. [31]
73
Metastases
Wieners et al. [36]
41
Metastases
Median 19.1 Gy
(1520)
Median 20 Gy
(1525)
Median 18.5 Gy
(1225)
Mean 2.85 cm
(0.810.7)
Median 3.1 cm
(113.5)
Mean 83.3 cm3
(4.5392)
10 % LR at 3
years
Mean LC
21.1 months
100 % LC at
median
15.4 months
100 % LC at
median
6.1 months
3-year LC
68.4 %
Mean LC 34
months
1-year LC
93.5 %
Ricke et al. [23]
37
Ricke et al. [22]
20
Primary/
metastases
Primary/
metastases
Median 18 Gy
(1020)
Median 17 Gy
(1225)
Median 4.8 cm
(2.511)
Mean 87 cm3
(7367)
9-month LC
87 %
9-month LC
80 %
Tselis et al. [35]
41
Primary/
metastases
Median 20 Gy
(732)
Median 84 cm3
(381348)
1-year Lc
primary 81 %
1-year LC
metastases
73 %
Mean 5 cm
(1.812)
Median
3.19 cm
(1.312)
Median 4.6 cm
(1.46.8)
Results
Median LC 10
months
1-year LC 95 %
1-year LC 96 %
Toxicity
3.7 % major
complications
7.2 % major
complications
No toxicity
reported
1 major
complication
1 major
complication
No
complications
1 perihepatic
hematoma
No major
complications
2.5 % major
complications
1.4 % major
complications
8.6 % minor
complications
41 % minor
complications
10 % major
complications
40 % minor
complications
5 % major
complications
15.2 % minor
complications
CT computed tomography, HDR right dose rate, BRT brachytherapy, LC local control, LR local recurrence
248
with an overall survival (OS) of mean

15.4 months. Wieners et al. [36] reported on 115
unresectable breast cancer metastases of median
4.6 cm (1.511 cm) in 41 patients. Treatment
consisted of single-fraction CT-guided 192Ir HDR
BRT of median 18.5 Gy (1225 Gy) yielding an
LC and OS rate of 93.5 and 79 % at 12 months,
respectively. Tselis et al. [35] generated an LC
rate of 79 % at 12 months for liver metastases and
88 % for primary hepatic tumors in 41 patients
treated with median 20 Gy in twice daily fractions
of median 7.0 Gy. The median tumor volume was
99 cm3 with an overall LC rate of 80 % at 1 year.
In analogy to tumor control, the rate of
complications is also consistent in many
published series on CT-guided HDR BRT for
unresectable liver tumors [21, 26, 3032, 36].
Mohnike et al. [30] performed 124 BRT sessions
in 83 patients with 140 HCC lesions. The authors
reported 7.2 % complications requiring
intervention with one case of treatment-related
death. Wieners et al. [36], however, only
documented 1.4 % toxicity necessitating
intervention (symptomatic post-interventional
hemorrhage) and 8.6 % complications which
were self-limiting. Tselis et al. [35] encountered
seven (16.5 %) minor and two (4.7 %) major
adverse events with no biliary toxicity, confirming
that fractionated HDR BRT can be applied at the
liver hilum without destroying the integrity of
ducts and vessels.
Local control alone as a clinical endpoint does
not necessarily reflect the full potential of HDR
BRT in the management of cancer patients with
liver-confined metastases. In situations of local or
even systemic progression, CT-guided HDR BRT
may be repeated in most cases. Two prospective
trials assessing survival of patients undergoing
multiple treatments against control are available,
one of which is a randomized trial on colorectal
liver metastases and one representing a matchedpair analyses in advanced HCC [30, 31]. In both
trials, increased patient survival was significantly
correlated with extensive or repeated CT-guided
BRT. In the HCC trial [30], survival after BRT
was doubled from 18 to 37 months with BRT, and
in the colorectal study [31], survival was highest
in patients receiving repeated BRT of evolving
new metastases at any location with a larger
N. Tselis et al.
benefit than further chemotherapy in a selected

salvage population.
Permanent IRT BRT techniques have also
been used in the liver. Numerous studies
employed intraoperative implantation of
iodine-125 (125I) seeds for LDR irradiation of
unresectable microscopic or gross residual disease [43, 71, 76]. Nag et al. [71] treated 64
patients with incomplete resection of intrahepatic malignancies by intraoperative 125I LDR
BRT with a median minimum peripheral dose
of 160 Gy. The median implant volume was
16 cm3. The overall LC rate was 44 % and
22 % at 12 and 36 months, respectively, with
an overall recurrence rate of 75 %. The authors
reported 9 % treatment-related complications
with one case of liver abscess and one case of
wound abscess. In contrast to LDR BRT as an
adjunctive modality after incomplete resection
of liver tumors, very few studies have employed
125
I implants for patients with liver malignancies who were not suitable for surgery. Lin
et al. [42] treated 23 patients with 65 inoperable HCC lesions by MRI-guided 125I LDR
BRT. The minimum dose was 144 Gy with a
total mean dose of 173 Gy. The overall response
rate was 84.5 %. The authors did not observe
any clinically relevant complications during
intervention and concluded that MRI-guided
LDR BRT is both technically feasible and
effective.
Stereotactic body radiation therapy has
emerged as a noninvasive technique to facilitate
dose escalation for the RT of extracranial tumors.
Doses in hypofractionated treatment schemes
range from 21 Gy in three fractions up to 60 Gy
in 36 fractions with local control rates from 55
to 100 % at 24 months [5760, 7783]. Similarly,
different schedules have been reported for singlefraction approaches with doses from 14 to 30 Gy
yielding control rates up to 86 % at 24 months
[57, 8386]. The median lesion volumes in the
largest reported SBRT studies range from 2.7 to
75.2 ml [57, 58, 60, 77, 78, 80, 8284]. In HDR
BRT series, the median lesion volumes are in the
range of 6199 cm3 with median tumor diameters
of 3171 mm ([22, 23, 2636, 46, 66, 7275]).
With this in mind, CT-guided IRT HDR BRT is
an effective alternative for patients who are not
candidates for SBRT due to extended tumor size

or central tumor location.
In conclusion, image-guided IRT HDR BRT is
a safe, effective treatment that is generally well
tolerated. It has been most useful in salvage
situations in patients with large hepatic tumors or
an intermediate number of lesions unsuitable for
thermal ablation or SBRT. In contrast to thermal
ablation, the technique is well suited to lesions
larger than 5 cm or in tumors close to or invading
large vessels. Hence, the technique is a valuable
adjunct in the large toolbox of interventional and
irradiation techniques for the treatment of
primary and metastatic liver cancers. In contrast
to other locoregional therapies, a higher accuracy
of dose delivery reliably leads to extensive cell
kill through biologic dose escalation. It is not
affected by any organ motion either intra- or
inter-fractionally since they can be corrected with
interactive online dosimetry during the
implantation procedure or modified during realtime anatomy-based 3D treatment planning
before dose delivery. Therefore, it may be the
least likely to entail unexpected pitfalls such as
the uncertainty of dose distribution caused by the
interplay effect when segmented or spotted
beams are used in EBRT techniques [87]. The
next evolutionary step for CT-guided HDR BRT
will be related to improvements of image
guidance for the interventional oncologist by
switching to MRI.
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2014.028
Gynecologic Brachytherapy:
Endometrial Cancer
John A. Vargo, Akila N. Viswanathan,
Beth A. Erickson, and Sushil Beriwal
Abstract
The management of endometrial cancer generally involves surgical extirpation of tumor as a primary therapeutic endeavor. Following surgery, and
in some cases in lieu of surgery (in medically inoperable patients), brachytherapy is frequently required as part of the definitive treatment scheme.
We present management guidelines and techniques in this chapter to aid in
the therapeutic management of these patients.
Introduction
In the United States, endometrial cancer represents

the most common gynecologic cancer and the 4th
most common cancer in females, with an estimated
49,560 new cases in 2013 [1]. In keeping with the
change in the 1988 FIGO staging from a clinical to
surgical staging system, the primary treatment for
J.A. Vargo, MD S. Beriwal, MD (*)
A.N. Viswanathan, MD, MPH
Department of Radiation Oncology, Brigham and
Womens Hospital and Dana-Farber Cancer Institute,
Harvard Medical School, Boston, MA, USA
B.A. Erickson, MD, FACR, FASTRO
Department of Radiation Oncology, Medical College
of Wisconsin, Milwaukee, WI, USA
endometrial cancer is surgical staging including hysterectomy and bilateral salpingo-oophorectomy

with or without pelvic and/or para-aortic nodal dissection. Adjuvant brachytherapy has a key role in
decreasing vaginal failures following surgical staging [2]. Endometrial cancer is most common in
patients of advancing age with multiple medical
comorbidities including obesity, cardiovascular disease, diabetes, and others. For patients who are unfit
for surgical staging, definitive radiation therapy,
including brachytherapy, remains a viable alternative for medically inoperable patients. Additionally,
while the majority of endometrial cancer patients
present with early-stage disease, some have locally
advanced disease extending to the cervix and parametria. For these locally advanced disease patients,
initial surgical staging with simple hysterectomy
may potentially transect disease; however a radical
hysterectomy is difficult in this population due to

DOI 10.1007/978-3-319-26791-3_14
253
J.A. Vargo et al.
254
their advanced age and associated medical comorbidities. Neoadjuvant radiotherapy, including external beam and brachytherapy, has been used to
downstage disease, affording a less extensive subsequent hysterectomy for these locally advanced
patients. Finally, for patients suffering a vaginal
recurrence following initial surgical staging alone,
radiotherapy, including external beam and brachytherapy, remains the preferred treatment modality
offering long-term salvage in up to 50 % of patients
with an isolated vaginal recurrence [3, 4]. The combination of external beam radiotherapy and brachytherapy has a clear role throughout the management
of endometrial cancer, much of which is explored in
detail in this chapter. Brachytherapy for vaginal
recurrence of endometrial cancer is detailed in the
following chapter.
Postoperative Vaginal Cuff

Brachytherapy: Indications
While the majority of patients with early-stage

endometrial cancers are cured with surgical staging,
1015 % of all surgically staged patients and up to
35 % of high-risk subsets will suffer pelvic relapse
[5]. Randomized trials, including GOG-99 and
PORTEC-1, have shown that adjuvant pelvic radiotherapy improved pelvic control without improving
overall survival [6, 7]. Given that 75 % of pelvic
relapses are isolated vaginal recurrences, PORTEC
2 was designed to address the question of whether
vaginal brachytherapy alone could rival outcomes
with external beam while decreasing treatmentrelated morbidity [8]. With no significant differences in vaginal (1.8 versus 1.6 %) or locoregional
(5.1 versus 2.1 %) recurrences comparing vaginal

brachytherapy to pelvic external beam radiotherapy,
PORTEC 2 established vaginal brachytherapy as an
important non-inferior treatment strategy for highto intermediate-risk early-stage endometrial cancers
[8]. Postoperative vaginal brachytherapy is tailored
to the findings at surgical staging and the projected
risk of vaginal recurrence according to a number of
well-defined histopathologic risk factors: stage,
depth of myometrial invasion, grade, histology,
lymphovascular space invasion, tumor size, and
lower uterine segment involvement. Age is also a
risk factor that is carefully considered. Balancing
these tumor and patient-related risks factors with
medical comorbidities, such as ulcerative colitis and
other conditions that may predispose patients to
treatment induced morbidity, remains important in
selecting patients for adjuvant brachytherapy.
Table 1 summarizes the National Comprehensive
Cancer Network (NCCN) guidelines for adjuvant
therapy following surgical staging in FIGO stage I
endometrial cancer, which are endorsed by the
American Brachytherapy Society as indications for
vaginal brachytherapy [9]. A comprehensive summary of indications for postoperative vaginal cuff
brachytherapy is found in the comprehensive executive summary evidence-based guideline from the
American Society for Radiation Oncology [10].

Brachytherapy: Technique
HDR vaginal cuff brachytherapy is performed

using a number of commercially available cylindrical vaginal applicators. The most appropriate
Table 1 Summary of indications for brachytherapy following surgical staging for FIGO stage I endometrial cancer
Stage IA without
risk factors
Stage IA with risk
factors
Stage IB without
risk factors
Stage IB with risk
factors
Grade 1
Observationa
Grade 2
Observationa
Observation or vaginal
brachytherapy
brachytherapy
Vaginal brachytherapy and/
or EBRT
brachytherapy
brachytherapy
brachytherapy and/or EBRT
Grade 3
brachytherapy
brachytherapy and/or EBRT
Vaginal brachytherapy and/or
EBRT
EBRT vaginal
brachytherapy chemotherapy
a
Part of ASTRO Choosing Wisely campaign, recommending Dont recommend radiation following hysterectomy for
endometrial cancer patients with low-risk disease. Potential risk factors include age >60, lymphovascular space invasion, tumor size, and lower uterine (cervical/glandular) segment involvement
Gynecologic Brachytherapy: Endometrial Cancer
255
applicator is selected based on the pre-application

assessment. The pre-application assessment begins
with a gynecologic examination to define vaginal
anatomy and to ensure appropriate healing of the
vaginal cuff with documentation of cuff integrity,
the absence of small bowel herniation through the
vaginal apex, and the absence of disease recurrence. Brachytherapy should be started as soon as
adequate healing is documented which is usually
48 weeks postoperatively and ideally not to
exceed a maximum of 12-weeks postoperatively
[11]. Based on the gynecologic examination, the
largest diameter cylinder is selected that the patient
can comfortably tolerate. This allows for maximal
vaginal distention, minimizing air pockets and
decreasing vaginal surface dose. Figure 1 highlights the difference in vaginal surface dose with
decreasing cylinder diameter. The total number of
cylinder segments is defined by the vaginal length;
typically one dome and two segments are used,
aiming for the cylinder not to extend outside of the

vaginal introitus unless the target includes the distal vagina. Most commonly for adjuvant vaginal
cuff brachytherapy, a single-channel applicator is
employed [12]. A multichannel applicator may
allow for differential loading to more conformally
shape the dose distribution. This can allow higher
dose to areas of residual disease and lower doses to
areas of subclinical disease. This represents a reasonable method of delivering vaginal brachytherapy, but the potential dosimetric benefits of a
multichannel cylinder versus a single-channel cylinder have yet to be proven clinically significant
[13, 14]. In addition, realization of the potential for
delivering excessive mucosal doses with a multichannel versus a single-channel applicator must be
made. Other applicators for vaginal brachytherapy
include ovoids, ring, or custom mold applicators,
which may improve vaginal mucosal dose in comparison to a cylinder by decreasing air pockets,
2.5 cm Cylinder
3 cm Cylinder
12.5 Gy
Surface
2.0 cm Cylinder
13.7 Gy
Surface
7 Gy
5mm
15.8 Gy
Surface
7 Gy
5mm
7 Gy
5mm
Fig. 1 The effects of vaginal cylinder size on vaginal surface dose. All representative doses are for a single fraction
with a prescription dose of 7 Gy to 0.5 cm depth
256
especially for patients with dog-ear vaginal anatomy [15, 16].

Patients are instructed to empty their bladder
prior to the procedure [17]. A bladder catheter is
not routinely inserted unless the patient is unable
to maintain bladder continence for the duration of
the procedure. Rarely bowel may lie in close
proximity to the vaginal cuff and the bladder can
be filled during treatment to displace the bowel
and significantly decrease bowel dose [18].
Following a detailed explanation of the proposed
application, the patient is placed in the dorsal
lithotomy position, while the selected cylinder is
measured, assembled, and coated generously
with a lubricant (consider use of lidocaine jelly to
reduce discomfort). By gently dilating the vagina
with a fingertip and then advancing the applicator
forward and dorsally, away from the urethra, the
applicator is advanced into the vaginal cuff. Once
at the cuff, confirmation that it is in contact with
the vaginal apex is made by exerting gentle cephalad pressure while monitoring the patient for discomfort. After returning the applicator to a more
neutral position, a perineal bar or other external
immobilization devices are secured, a radiopaque
marker wire is placed in the central channel, and
the patients legs are positioned in a more natural
supine position supported on pillows. Once in the
legs down position, the applicator should again be
checked for its contiguity with the vaginal apex
by exerting gentle pressure and releasing to a neutral position and again securing the applicator
with the immobilization device.
Two important potential sources for error at
the first vaginal brachytherapy insertion are lack
of approximation of the applicator with the vaginal apex and selection of the wrong size or shape
of applicator. There are a number of different
techniques for confirming that the applicator is in
contact with the vaginal apex. Two orthogonal
radiographs (AP and lateral) can be taken to confirm appropriate placement relative to a radiopaque fiducial marker placed at the time of
gynecologic examination or matching the applicator length with the pre-insertion vaginal length.
CT evaluation is, however, preferred to allow
three-dimensional dosimetric evaluation. Another
potential error is to insert the wrong diameter cyl-
J.A. Vargo et al.
inder at repeat fractions. At the time of the first

and subsequent insertions, vaginal cylinder diameter should always be measured and confirmed
with the measurement of prior insertions. As a
second safety confirmation, the cylinder diameter
can be measured on the orthogonal films or CT
images to document that the appropriate diameter
cylinder was placed. A CT simulation is performed for the first fraction of vaginal cuff
brachytherapy with a non-contrast-enhanced CT
from the mid-pelvis to below the ischial tuberosities using a 0.25 cm slice thickness. CT-based
planning offers a number of clinical advantages
(see Fig. 2): 3-dimensional (3D) confirmation of
appropriate applicator placement and cuff integrity (see Fig. 2a), assessment of dose relative to
the thickness of the rectovaginal septum and apical vaginal tissue (see Fig. 2bc), and assessment
of air pockets created between the vaginal mucosa
and the applicator (see Fig. 2d) [19]. As the clinical significance of interfraction changes in 3D
planning is small for most patients, we do not
routinely advocate 3-D planning with each fraction, but rather confirmation of applicator placement on orthogonal films or CT scan imaging
with subsequent insertions [20]. On the planning
CT, the clinical target volume and critical organs
(the bladder, rectum, and small bowel) can be
contoured. The clinical target volume typically
includes the proximal 35 cm of vagina, except
for patients with type II histology (clear cell carcinoma and uterine papillary serous carcinoma)
or extensive lymphovascular space invasion
where treating the entire length of the vagina
should be considered for treatment [2]. However,
many of these patients with type II histology or
extensive lymphovascular space invasion have
other risk factors that would favor treatment with
a combination of external beam radiotherapy and
brachytherapy, wherein the entire vagina could
be treated with the external beam fields and
brachytherapy would be used to boost just the
proximal vagina to minimize the morbidity of
treating the entire vagina with brachytherapy.
The plan is optimized using points in the apex,
curvature of the cylinder dome, and the lateral
vaginal mucosa as detailed in the American
Brachytherapy Society guidelines [2].
257
Fig. 2 Benefits of image-based brachytherapy for vaginal

cuff brachytherapy. (a) Inadvertent perforation of the
vaginal apex with vaginal cylinder placement (highlighted
by arrow) which is easily recognizable on the CT-image
completed for image-based planning. (b) A thinned
submillimeter rectovaginal septum (highlighted by arrow)
for which a higher dose to the rectum would be
administered using two-dimensional planning; however,
with image-based planning, the rectal dose was reduced

by 14 % over a standard two-dimensional plan. (c)
Thickened vaginal apex measuring 0.82 cm (highlighted
by the arrow) for which image-based planning increased
the D90 % to the CTV as compared to a standard twodimension plan. (d) Air pockets between the vaginal
mucosa and cylinder surface (highlighted by the arrow)
which can be accounted for in image-based planning
A variety of dose fractionation schemas are

employed [12]. For brachytherapy alone, as used
in the PORTEC 2, a dose of 7 Gy times 3 fractions
specified at a depth of 0.5 cm is a frequently used
fractionation schedule [8]. Others have favored
using more protracted fractionation schemas
including 6 Gy times 5 fractions (M.D. Anderson)
or 4 Gy times 6 fractions (Dana-Farber/Brigham
and Womens) prescribed to the cylinder surface
in an attempt to decrease the vaginal surface dose
and subsequent late vaginal morbidity including
fibrosis, telangiectasia, dryness, shortening, and
narrowing [21]. The American Brachytherapy
Society consensus guidelines mention a number
of dose fractionation schemes and however purposely do not endorse any one schema over
another as there is little agreement when it comes
to dose fractionation schemes [2, 12]. A random-
ized study by Sorbe et al. showed that vaginal

recurrence rates were similar between 2.5 and
5 Gy times 6 fractions prescribed to 0.5 cm depth,
with less vaginal shortening with the 2.5 Gy per
fraction schema [22]. The ongoing PORTEC 4 is
currently comparing 15Gy to 21Gy over 3 fractions prescribed to a 0.5 cm depth to prospectively
define if lowering the dose per fraction can maintain excellent tumor control while decreasing the
long-term risks of vaginal morbidity. For a brachytherapy boost following external beam, doses
such as 6 Gy times 23 fractions prescribed to the
cylinder surface based on risk factors with external beam radiotherapy doses of 4550.4 Gy are
reasonable and concordant with dose fractionation schemas used in contemporary cooperative
group trials such as (RTOG 0921 and 0418). As
detailed in Fig. 1, it is important to consider the
J.A. Vargo et al.
258
increasing vaginal surface dose with decreasing

cylinder size. For patients with a narrow vagina
necessitating a 2.02.5 cm cylinder, consideration
of decreasing the brachytherapy dose per fraction
is warranted. For HDR brachytherapy, daily fractionation is not recommended, and multiple fractions per week are favored using at most an
every-other-day application.

Brachytherapy: Alternate
Techniques
While recent international patterns of care have

shown 85 % utilize HDR brachytherapy techniques,
viable alternatives include LDR and PDR brachytherapy techniques [23]. LDR brachytherapy commonly requires the patient to remain in the hospital,
with some component of analgesia, immobilization
precautions (deep vein thrombosis prophylaxis),
bladder catheter placement, antidiarrheals (to prevent bowel movements), and special precautions to
maintain applicator placement. The treatment duration varies according to the dose and dose rate chosen. Historical doses include approximately 60 Gy
LDR to the vaginal surface at a dose rate of
60100 cGy/h for adjuvant vaginal brachytherapy
alone and a combined external beam radiotherapy
and LDR equivalent of 70 Gy to the vaginal surface
when brachytherapy is used as a boost following
external beam radiotherapy.

Brachytherapy: Quality
and Reporting Standards
A detailed, signed prescription including the treatment site, prescription point(s), total dose, dose per
fraction, number of fractions, where the dose is specified, and radioisotope is imperative. It is recommended that both the dose to 0.5 cm and the vaginal
surface be documented. While no specific validated
volumetric constraints for CT-based planning in
vaginal cuff brachytherapy are currently available,
we recommend that the dose to rectum and bladder bowel (depending on proximity) is recorded
usually as D2cc. There are several AAPM task group
publications that serve as invaluable resources for

brachytherapy quality assurance [2427].

Brachytherapy: Results
Two important randomized trials place the comparative effectiveness of adjuvant brachytherapy
following surgical staging for endometrial cancer
in the context of observation and pelvic external
beam radiotherapy. Sorbe et al. completed a
multi-institutional trial which compared surgical
staging to surgical staging plus adjuvant brachytherapy alone in low-risk (FIGO grades 12, with
50 % myometrial invasion) endometrioid endometrial cancers [28]. At a mean follow-up of 68
months, adjuvant brachytherapy alone leads to a
non-significant (60 %) decrease in vaginal failures (3.1 versus 1.2 %, p = 0.114) with no grade
3+ complications in either arm, suggesting that
brachytherapy reduces the rates of vaginal recurrence without significantly increasing complications; however in subgroups with a low rate of
recurrence following surgical staging (FIGO
stages 1A1B, grades 12, without risk factors),
there is likely limited benefit to adding brachytherapy over close observation following surgical
staging [28]. Similarly in PORTEC 2, vaginal
brachytherapy alone was compared to pelvic
external beam radiotherapy in a prospective phase
III setting showing no significant difference in
vaginal recurrence (1.8 versus 1.6 %, p = 0.74),
locoregional relapse (5.1 versus 2.1 %, p = 0.17),
disease-free survival (83 versus 78 %, p = 0.74), or
overall survival (85 versus 80 %, p = 0.57); however brachytherapy resulted in significantly lower
gastrointestinal toxicity (grades 12 13 % versus
54 %) [8]. These results from PORTEC 2 highlight that brachytherapy can maintain improvements in pelvic control while decreasing toxicity
relative to pelvic external beam radiotherapy for
intermediate-risk patients [8]. Table 2 summarizes additional results for select series using
HDR brachytherapy with >100 included patients
[8, 2834]. Despite differences in patient selection, technique, and follow-up across the studies,
Table 2 consistently highlights that vaginal
brachytherapy alone results in low rates of vaginal
259
Table 2 Results for adjuvant vaginal brachytherapy alone following surgical staging for endometrial cancer
Study
Swedish Randomized [28]
PORTEC 2 [8]
Orebro Medical Center, Sweden [29]
Royal Prince Alfred, Australia [30]
University of Goettingen [31]
University of Arizona [32]
Swedish Medical Center [33]
Memorial Sloan Kettering [34]
n
319
213
404
141
122
102
164
382
Treatment
38 Gy 36 at 0.5 cm
7 Gy 3 at 0.5 cm
4.59 Gy 46 at 1 cm
8.5 Gy 4 at surface
7 Gy 3 at surface
5 Gy 3 at 0.5 cm
7 Gy 3 at 0.5 cm
7 Gy 3 at 0.5 cm
failure to 2 % and is associated with an exceedingly low risk of severe grade 3+ complications
2 % [8, 2834]. The potential added benefits of
a brachytherapy boost following pelvic external
beam radiotherapy remain less well established
[35]. However, numerous series have similarly
documented low rates of recurrence and toxicity
with the combination of external beam radiotherapy and vaginal brachytherapy boost [36, 37]. A
randomized Norwegian trial attempted to evaluate
the additional benefit of pelvic external beam
radiotherapy to surgical staging and low-dose-rate
vaginal brachytherapy to 60 Gy at the vaginal surface [38]. Randomizing 540 stage I patients, pelvic external beam radiotherapy reduced the rates
of vaginal/pelvic failure (5 % versus 20 %) and
improved death from cancer (18 versus 28 %)
only in patients with deeply invasive (>50 % myometrial invasion) and grade 3 tumors, highlighting
that the combination of external beam radiotherapy plus brachytherapy may be best reserved for
high-risk patients [38]. Careful attention to bladder and rectal doses in patients receiving combined external beam and brachytherapy is required
to minimize late morbidity which has been
observed in some historical series.

Brachytherapy:
Complications
and Management
Acute side effects of vaginal cuff brachytherapy

typically include vaginitis and rarely mild cystitis
or proctitis. Rare irritation of the small bowel,
Vaginal
recurrence
1.2 %
1.8 %
0.7 %
1.4 %
1.6 %
1.0 %
1.2 %
0.8 %
5-year overall
survival
96 %
85 %
92 %
91 %
94 %
84 %
87 %
93 %
Grade 3+
complications
0%
2.3 %
NR
0%
0%
0%
0%
1%
with associated diarrhea, can occur in patients

with small bowel gravitating to the pelvic floor.
These side effects are commonly self-limited and
resolve without intervention. The predominant
complications of concern following vaginal
brachytherapy are vaginal dryness, vaginal telangiectasia leading to bleeding, and vaginal fibrosis
leading to narrowing and shortening of the vagina
which potentially compromise sexual function
and quality of life [39]. In PORTEC 2, while
brachytherapy decreased the rates of gastrointestinal toxicity as compared to pelvic external beam
radiotherapy (grade 12 gastrointestinal toxicity
13 % versus 54 %, grade 3 gastrointestinal toxicity <1 % versus 2 %), rates of vaginal atrophy
were slightly increased with vaginal brachytherapy (grade 3 vaginal atrophy 2 % versus <1 %)
[8]. With long-term follow-up, patient-reported
quality of life analysis from PORTEC-2 highlighted that vaginal brachytherapy improved
social functioning and decreased bowel symptoms including diarrhea and fecal leakage, but
did not improve sexual function as compared to
pelvic external beam radiotherapy [40]. To mitigate risks of late vaginal dysfunction, a vaginal
dilator is commonly recommended following
radiation which helps to maintain patency of the
vagina by disrupting the formation of adhesions
and fibrous tissue, typically advocating for use at
minimum two to three times per week beginning
within 1 month following the completion of
brachytherapy [4143]. Ongoing studies are currently looking at modifications such as vibrator
use, which may help to further reduce vaginal
brachytherapy morbidity and improve long-term
patient quality of life.
J.A. Vargo et al.
260
Denitive Brachytherapy
for Medically Inoperable
Endometrial Cancer:
Indications
Despite improvements in surgical technique,

including minimally invasive laparoscopic and
robotic techniques, an ever aging population of
patients with significant comorbidities leads to
49 % of endometrial cancer patients to be
considered medically inoperable [4447]. The
combination of advancing age and a multitude of
medical comorbidities (obesity, diabetes,
cardiovascular disease, etc.) places this cohort of
endometrial cancer patients at a higher risk of
death from intercurrent disease (approximately
threefold greater risk of death from causes other
than endometrial cancer) or from surgery than
from their cancer [48]. Nonetheless, definitive
radiotherapy, either via brachytherapy alone or a
combination of external beam radiotherapy plus
brachytherapy, remains an important treatment
aimed at controlling disease and maintaining
quality of life.
Endometrial Cancer:
Technique
HDR brachytherapy for medically inoperable

endometrial cancer can be completed either as
monotherapy or as a boost following external
beam irradiation. The optimal technique
depends on the patients performance status and
the staging imaging if technically feasible.
Staging imaging should include pelvic MRI
whenever feasible. Additionally for patients
with high-grade disease, a CT of the chest,
abdomen, and pelvis or whole body PET/CT to
assess for regional nodal involvement or distant
metastases should be considered. Pelvic MRI
can reveal tumor size as well as the presence
and depth of myometrial invasion and the presence of cervical extension superior to CT or
ultrasound [4951]. This information is critical
in defining the role and type of brachytherapy in
addition to the need for external beam irradiation. For patients with FIGO grade 12 endometrioid endometrial carcinoma, with <50 %
myometrial invasion and low-volume disease
(2 cm), brachytherapy alone can be used,
while for patients with high-grade disease, deep
myometrial invasion, or large-volume disease, a
combination of external beam irradiation
followed by a brachytherapy boost is generally
recommended as these patients are a higher risk
for extrauterine extension (most notably pelvic
node involvement) which will be inadequately
covered with brachytherapy alone. Additionally,
this pre-brachytherapy assessment helps to
define the optimal brachytherapy applicator and
dose. The most common applicators include an
intracavitary tandem and cylinder or a dual-tandem or Y applicator, a triple-tandem applicator,
or a modified Heyman packing. At the exam
under anesthesia, the uterine sound length is
measured to define the tandem length required
and the vaginal vault size assessed for optimal
vaginal applicator selection. Typically the largest size that can be accommodated is selected.
For institutions favoring an intracavitary applicator, a maximum uterine width >45 cm by
pre-brachytherapy imaging helps to select for
patients in which the full thickness of the uterus
may be under-dosed with a single-tandem-cylinder applicator (see Fig. 3a). For these patients
with a maximum uterine width >5 cm, a dualtandem Y applicator (see Fig. 3b) or triple-tandem applicator may more optimally cover the
full thickness of the uterus [44, 52]. Applicator
selection should be defined based on the individual patient anatomy; a dual-tandem Y applicator may help improve lateral coverage over a
single-tandem applicator while a triple-tandem
may increase coverage both laterally and in an
anterior/posterior direction [44, 52]. However
the inherent challenges in inserting two or three
tandems and the associated prolonged immobilization and anesthesia requirements may make
them suboptimal for some medically inoperable
patients (such as those with baseline coagulopathy or baseline orthopnea from underlying congestive heart failure, sleep apnea, or other
similar comorbidities). There is also increased
261
Fig. 3 Uterine width limitations of single-tandem

brachytherapy ameliorated with a Rotte Y applicator. (a)
Pre-brachytherapy MRI showing a maximal uterine width
measuring 9.1 cm which would be inadequately covered
with a single-tandem applicator. (b) Image-based
brachytherapy plan for the same patient treated with a

Rotte Y applicator to improve lateral coverage. For panel
b: GTV (green dotted line), CTV (red dotted line), 150 %
isodose line (yellow solid line), 100 % isodose line (red
solid line), and 80 % isodose line (green solid line)
risk of perforation with multiple tandems.

Others have favored using modified Hyman
packing (Norman Simons applicators) which
consist of capsules of varying sizes (usually
between 0.4 and 0.8 cm selected based on prebrachytherapy assessment for packing within
the uterine fundus) mounted on long flexible
tubing [53, 54]. The modified Heyman packing
also requires insertion under anesthesia for
insertion of multiple capsules (518 capsules)
and prolonged immobilization which, as the
dual and triple tandems, is challenging in these
medically inoperable endometrial cancer
patients. This sometimes makes the single-tandem and vaginal cylinder applicator the most
reasonable choice.
The brachytherapy procedure begins with
some component of analgesia, such as IV conscious sedation, spinal or epidural anesthesia, a
paracervical block, or oral pain medication,
depending on the applicator type and patient tolerance both to pain and considering the risks
associated with increasing depth of analgesia. In
some patients a combination of IV sedation and
a paracervical block can be helpful in achieving
improved comfort while lowering the associated
risks. Patients should always be evaluated for

anesthesia risk prior to the procedure. The
patient is placed in the dorsal lithotomy position
with a bladder catheter inserted to empty the
bladder. Using downward traction as needed,
the tandem is inserted through a previously
placed Smit sleeve, with subsequent vaginal
dome segments threaded onto the tandem to
optimally fill the vagina without undue discomfort, ranging in size from 2.0 to 4.0 cm. For
patients whose placement is difficult or those
requiring a dual- or triple-tandem applicator,
ultrasound can be used for image guidance during applicator placement. Following applicator
placement, if possible, image-based planning
should follow to allow for confirmation of
appropriate applicator placement relative to the
3-dimensional anatomy and to maximize dose
to the target while minimizing dose to critical
organs [55]. Others have published their
experience using image-based planning for
modified Heyman packing [54]. The American
Brachytherapy Society guidelines for medically
inoperable endometrial cancer are currently
being updated and underscore the importance of
imaging and volumetric rather than just point-
262
based planning. Additional information regarding the technique for point-based planning as
outlined in the 2000 American Brachytherapy
Society guidelines will be reviewed in the alternate technique section below [56]. Here the
technique description will focus on the preferred
technique of image-based planning. Following
applicator insertion, a T2-weighted MRI
(or non-contrast-enhanced pelvic CT in patients
with a contraindication to MRI or with a uterine
length >8 cm for which the availability of a
MRI-compatible tandem is limited) is obtained
with the applicator in place and with each subsequent fraction. The GTV is the entire endometrial cavity (in patients with no identifiable gross
tumor at the time of brachytherapy) plus any
gross tumor visualized at the time of brachytherapy. The CTV is defined to include the GTV
plus the entire uterus, cervix, and upper 12 cm
of the vagina. When HDR brachytherapy is integrated with pelvic external beam radiotherapy
(usually to 45 Gy at 1.8 Gy per fraction), brachytherapy doses range from 4 to 5.5 Gy times 45
fractions based on response to external beam,
extent of disease, and normal tissue proximity
aiming for the CTV to receive a dose sufficient
for microscopic disease between 45 and 60 Gy
EQD2Gy, whereas the GTV receives a boost to an
EQD2Gy of at least 8090 Gy. Fewer HDR fractions are also reasonable if the organs at risk are
in close proximity to the uterus and/or the uterine wall is thin. Brachytherapy planning is completed first by optimizing to point W (2 cm
inferior from the tandem tip along the tandem
and then lateral to the mid-uterine width or
approximately 2 cm) and then using manual
optimization to achieve a CTV D90 % 100 %
while maintaining a rectal D2cc EQD2Gy 70 Gy,
sigmoid D2cc 70 Gy, and bladder D2cc 80 Gy
[57]. Other recommended dose fractionation
schemas for HDR brachytherapy following
external beam radiotherapy (45 Gy at 1.8 Gy per
fraction) as outlined in the American
Brachytherapy Society guidelines are 8.5 Gy
times 2 fractions, 6.3 Gy times 3 fractions, and
5.2 times 4 fractions [56]. For brachytherapy
alone, 8.5 Gy times 4 fractions, 7.3 Gy times 5
fractions, 6.4 Gy times 6 fractions, or others are
J.A. Vargo et al.
possible options for fractionation schemas [56].

Recognizing that medically inoperable patients
are at a threefold higher risk of death from intercurrent disease, a higher priority is placed on
critical organ constraints than CTV coverage
[48]. These patients cannot afford to have a
complication as the intervention for the complication could be life threatening. HDR
brachytherapy with a tandem-cylinder applicator is completed on an outpatient basis, using at
maximum every-other-day fractionation. If
there is concern about the sedation required for
applicator insertion, it is possible to hospitalize
the patient and deliver two to three fractions for
each insertion of the applicator. The risks of bed
rest must be balanced with the risks of multiple
sedations.
For patient requiring a dual- or triple-tandem
applicator, MRI-compatible applicators are not
yet commercial available; thus CT-based planning is used. Due to the difficulty in applicator
placement, these applications are completed on
an inpatient basis. The applicator is placed
under anesthesia in the operating room with full
relaxation to allow for uterine dilation. For a Y
applicator, the two curved tandems are selected
to the measured uterine length and then gently
advanced toward the opposite uterine cornu
under ultrasound guidance. The two tandems
are subsequently fixed together and vaginal
packing is inserted to keep the applicator in
place and displace the rectum and bladder.
Following applicator placement, the labia can
be sutured to prevent applicator extrusion from
the vagina. Confirmation of placement and
image-based planning is completed using a noncontrast-enhanced pelvic CT with the applicator
in place. Contrast can be inserted into the rectum and sigmoid as well as the bladder to better
define these critical organs. For patients receiving a combination of external beam radiotherapy plus brachytherapy, a dose 45 Gy times 5
fractions delivery twice daily with a minimum
inter-fraction interval of 6 h is used, while for
those receiving brachytherapy alone, 77.5 Gy
times 5 fractions delivered twice daily with a
minimum inter-fraction interval of 6 h is used
with a similar optimization and planning tech-
nique as described above for a single-tandemcylinder application. Similarly, the American

Brachytherapy Society guidelines recommend a
dose per fraction of 7.3 Gy when 5 fractions are
used for brachytherapy alone and 5.2 Gy per
fraction for up to 4 fractions following external
beam radiation therapy, among other possible
acceptable options [56].
10
Endometrial Cancer:
Alternate Techniques
Brachytherapy planning can be either image based

(preferably) relative to cross-sectional imaging or
point based relative to fixed geometry or localization radiographs (Ap and lateral or stereoshift
radiographs). Relying on point-based planning
increases the risk of complications over imagebased planning in a medically inoperable population vulnerable to serious complications [58].
Integration of image-based planning allows for
dose painting such that the high dose is confined to
the defined areas of disease, which is not feasible
with point-based planning [55, 58]. The intended
target volume for point-based planning includes
the uterus, cervix, and proximal 35 cm of vagina,
with recommendations to aim for the prescription
isodose line to include the entire uterine serosa and
vaginal wall (to 0.5 cm depth). The dose is specified to a point defined as 2 cm from the central axis
at the midpoint along the uterine applicator. The
prescription at the vaginal level can be adjusted
depending on the cylinder diameter to meet the
0.5 cm prescription depth or a surface dose prescription. Traditional International Commission of
Radiation Units (ICRU) points for rectum and
bladder are used to record critical organ doses.
Assessment of dose to the sigmoid is also critical
in this population where the sigmoid is often close
to the uterus. This technique of attempting to cover
the entire uterus is technically challenging and
often not feasible when considering normal tissue
constraints; therefore point-based planning should
be avoided in favor of image-based planning in the
modern brachytherapy era [59].
263
11
Endometrial Cancer: Quality
A detailed, signed prescription including the treatment site, prescription point, total dose, dose per
fraction, fractionation, and radioisotope is again
imperative. Prescribed dose is recorded as D90 % for
the contoured CTV, aiming for a D90 % 100 %
when image-based planning is incorporated. We
recommend that the critical organ doses be carried
across brachytherapy fractions and incorporate any
external beam radiotherapy dose, using an EQD2Gy
calculator, aiming for the rectal D2cc EQD2Gy
70 Gy, sigmoid D2cc 70 Gy, and bladder D2cc
80 Gy. There are several American Association
of Physicists in Medicine (AAPM) task group publications that serve as invaluable resources for
brachytherapy quality assurance [2427].
12
Endometrial Cancer: Results
The importance of brachytherapy utilization for

inoperable endometrial cancer was highlighted in
a recent Surveillance, Epidemiology, and End
Results (SEER) analysis from 2004 to 2010,
which showed that despite only 5 % brachytherapy utilization, inoperable endometrial cancer
patients treated with brachytherapy had significantly improved overall survival with a 3-year
overall survival of 4559 % (depending on age)
compared to 2123 % for external beam radiotherapy alone (p < 0.001) [60]. However, owing to
the uncommon nature of medically inoperable
endometrial cancer, the body of literature supporting definitive brachytherapy for endometrial
cancer is confined to retrospective cohort studies,
the largest of which is from Vienna. Reporting on
their institutional experience for 280 inoperable
endometrial cancer patients (84 % stage I) predominately treated with HDR brachytherapy
alone, at a median follow-up of 49 months, the
5-year disease-specific survival and local control
rates were 76 and 75 % with a 5-year probability
J.A. Vargo et al.
264
of grade 3 late complications of 5.2 % [61].

Similarly in a multi-institutional collaboration
including 74 patients from five large US academic
cancer institutions, the median progression-free
survival was 44 months and overall survival was
47 months with a hazard ratio for risks of death
from causes other than endometrial cancer of 3.4
(95 % CI 1.49.4, p = 0.003) again highlighting
the burden of comorbidity and competing risks of
mortality in this cohort of endometrial cancer
patients [48]. More recently, image-based brachytherapy has been integrated in the management of
medically inoperable patients which has translated into high local control rates 9192 % and no
grade 3+ complications across two international
series; further follow-up will help to better define
if these high rates of local control and low rates of
complication relative to older two-dimensional
series are maintained [54, 55].
13
Endometrial Cancer:
Complications
and Management
In the largest series using definitive brachytherapy for endometrial cancer from the Vienna
group, overall rates of complications were low
with only 12.5 % of patients experiencing any
acute side effects (9.1 % were grade I involving
the rectum, bladder, or vagina which resolved
without interventions) and 21 % of patients experiencing any late complication (5.2 % of which
were grade 34 complications, the majority of
which were small bowel complications with a
3.5 % grade 34 bowel complications) [61].
These severe late small bowel complications
often require surgical intervention in a challenging subset of patients. Image-based planning may
help to reduce this risk of bowel complications
over two-dimensional planning by accounting for
small bowel and sigmoid dose [58]. Moreover,
one treatment-related death in the Vienna series
was due to an unrecognized perforation during
the application resulting in small bowel necrosis
and peritonitis [61]. This highlights the impor-
tance of careful applicator placement as the postmenopausal uterine wall is often thin and
recognition of applicator perforation prior to
treatment. It also highlights one of the important
advantages of image-based planning over conventional two-dimensional point-based planning.
14
for Locally Advanced
Disease: Indications
Locally advanced endometrial cancer extending

to the cervix at presentation is an uncommon and
challenging presentation. Two potential plans of
care thus exist:
1. Radical hysterectomy (if feasible) followed
by tailored adjuvant therapy
2. Neoadjuvant radiochemotherapy (including a
combination of external beam radiotherapy
plus brachytherapy) to downstage disease
followed by extrafascial hysterectomy
15
Disease: Techniques
Preoperative brachytherapy for locally advanced

endometrial cancer is not covered in the previous
guideline publications from the American
Brachytherapy Society; thus the presented technique reflects the current practice. For patients with
disease clinically extending to the cervix/parametria, these clinical findings are confirmed with additional pre-brachytherapy imaging including a
pelvic MRI and PET/CT. If extension to the cervix/
parametria is confirmed, preoperative external
beam radiotherapy (with concurrent weekly cisplatin) is planned with the volume of treatment to
include the pelvis only up to the common iliac
nodal regions for patients whose PET/CT is negative for nodal disease. For patients with nodal disease, the pelvis plus para-aortic nodes +/ a
simultaneous integrated boost to the positive nodes
is recommended [62]. In the 4th or 5th week of
chemoradiotherapy, patients undergo a repeat exam
265
under anesthesia to assess response and an

MR-compatible Smit sleeve is placed followed by
34 fractions of image-based HDR brachytherapy.
The sound length of the uterus at the time of exam
under anesthesia helps to define the required tandem length and the extent of disease defines the
applicator selection. Brachytherapy is completed
using either a tandem-ring (preferred applicator),
tandem-cylinder (used at our institutions primarily
when a tandem length of 8 cm or greater is required),
or template-based interstitial applicator. HDR
brachytherapy is completed as an outpatient, with at
maximum every-other-day fractionation. A bladder
catheter is placed prior to beginning the procedure
with either oral analgesia or conscious sedation
incorporated. The patient is placed in the dorsal
lithotomy position, and the tandem is inserted with
ultrasound guidance used on an as-needed basis
based on the difficulty of insertion. Then, either the
ring or subsequent dome segments are assembled
accordingly with rectal retraction or vaginal packing per institutional practice. The patient is returned
to a more comfortable supine position with placement of an external stabilizing device such as a
perineal bar. HDR brachytherapy is completed
using image-based planning with each fraction,
with T2-weight pelvic MRI as the preferred imagebased planning modality. CT-based brachytherapy
planning is used for patients with a contraindication

to MRI or for those requiring non-MRI-compatible
applicators (based on institutional availability). The
CTV includes the gross tumor volume plus the
entire uterus and cervix (see Fig. 4). Fractionation
schedules vary between 5 and 5.5 Gy times three to
four fractions, aiming for a cumulative EQD2Gy of
6070 Gy modulated based on response and extent
of disease. The plan is first optimized to point A,
with subsequent manual optimization aiming for a
CTV D90 % 100 % while maintaining a rectal D2cc
EQD2Gy 65 Gy, sigmoid D2cc 65 Gy, and bladder
D2cc 70 Gy (see Fig. 4). Restaging CT imaging is
performed 45 weeks following completion of
chemoradiotherapy followed by extrafascial hysterectomy at a 48-week-interval post-completion of
neoadjuvant brachytherapy.
Fig. 4 MRI-based
planning
for
preoperative
brachytherapy in locally advanced endometrial cancer
clinical extending to the cervix. The GTV at the time of
brachytherapy is outlined in green. The CTV is outlined in
red, which incorporates the GTV plus the entire uterus
and cervix. The isodose cloud highlights MRI-based

planning where the yellow cloud represents the 150 %
isodose, red represents to 100 % isodose, and green represents the 80 % isodose
16
Disease: Alternate
Techniques
An alternative technique would be to use LDR

as described in the older University of Kentucky
experience [63, 64]. Preoperative brachytherapy
using LDR would include all the above steps for
J.A. Vargo et al.
266
applicator placement; however additional consideration of prolonged immobilization and

radiation exposure would apply. This older
technique described traditional point-based
planning to point A while limiting the maximum point dose to the rectum and bladder of
80 % of the prescription dose using the ICRU
points previously described for gynecologic
cancer planning.
17
Disease: Quality
A detailed, signed prescription including the

treatment site, prescription point, total dose, dose
per fraction, fractionation, and radioisotope is
again imperative. Prescribed dose is recorded as
D90 % for the contoured CTV, aiming for a D90 %
100 % when image-based planning is incorporated. We recommend that the critical organ
doses be carried across brachytherapy fractions
and incorporate any external beam radiotherapy
dose, using an EQD2Gy calculator, aiming for the
EQD2Gy rectal D2cc 65 Gy, sigmoid D2cc 65 Gy,
and bladder D2cc 70 Gy. There are several
AAPM task group publications that serve as
invaluable resources for brachytherapy quality
assurance [2427].
18
Disease: Results
Larger series from the 2-dimensional non-imagebased era showed the potential value of a neoadjuvant radiotherapy approach to a total dose of
6065 Gy with a combination of external beam
radiotherapy and LDR brachytherapy using a tandem and cylinder applicator evincing an 88 %
5-year overall survival with only 5 % vaginal failure [63, 64]. These results have been more
recently validated in the image-based HDR
brachytherapy era, with a similar 3 % vaginal
failure and 100 % 3-year survival [62].
19
Disease: Complications
and Management
One potential concern of a preoperative approach

is the potential for increasing surgical
complications following neoadjuvant therapy. A
recent detailed analysis of surgical complications
following neoadjuvant chemoradiation therapy
and extrafascial hysterectomy showed acceptable
low rates of postoperative ileus and vaginal cuff
dehiscence of 10 and 3 %, respectively [65]. This
suggests that neoadjuvant therapy does not
increase complications over upfront surgical
staging followed by tailored adjuvant therapy.
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Gynecol Oncol 137(Suppl 1):1210
Cervical Cancer
Abstract
Cervical cancer is the 3rd most common malignancy in the world. Despite
national trends of declining utilization, brachytherapy plays an integral role in
the curative management of all locally-advanced and medically inoperable
early-stage cervical cancer. Herein we review the practice implementation of
brachytherapy critical to curing patients of cervical cancer, especially modern
image-based high-dose rate brachytherapy.
Introduction
Over 275, 000 women die of cervical cancer per

year worldwide, with cervical cancer representing
the 3rd most common cancer in women [1, 2].
Brachytherapy is an integral part of cervical cancer
management which has consistently been shown to

improve overall survival [36]. Despite the consistent survival improvement associated with brachytherapy utilization, in the context of modern
radiation therapy such as intensity-modulated radiation therapy and stereotactic body radiation therapy, brachytherapy utilization has decreased which
has led to a survival decrement [5, 6].
2
Boston, MA, USA
Department of Radiation Oncology, Medical College
of Wisconsin, Milwaukee, WI, USA
Indications
Surgery is generally considered the preferred

curative treatment for early-stage IA cervical
cancer because of the opportunity for fertility and
ovarian preservation in premenopausal women,
decreased risk of second cancers, and decreased
overall treatment time. However for medically
inoperable patients with International Federation
of Gynecology and Obstetrics (FIGO) stage IA1
IB1 cervical cancer, definitive radiation therapy
is the preferred alternative to surgery. Radical

DOI 10.1007/978-3-319-26791-3_15
269
J.A. Vargo et al.
270
hysterectomy ( adjuvant external beam

radiotherapy) and definitive radiation therapy
result in equivalent cancer-specific and overall
survival for patients with clinical stage IBIIA
cervical cancer, with increased acute and late toxicity in those patients requiring radical hysterectomy plus adjuvant radiotherapy [7]. Intravaginal
brachytherapy may selectively be integrated with
adjuvant external beam radiotherapy for intermediate- and high-risk patients following surgery,
especially when only a simple hysterectomy has
been performed inadvertently or when vaginal
margins are close or positive. For all patients with
clinical node-positive or locally advanced cervical cancers (stages IB2IVA), concurrent cisplatin-based chemoradiotherapy with the addition of
brachytherapy is the accepted standard.
Technique
Comprehensive staging and disease assessment is

critical; thus a thorough gynecologic examination
and cross-sectional imaging are essential to guide
the plan of care based on the clinical stage. Pelvic
MRI with water-based vaginal gel to enhance vaginal contrast is a more sensitive test for parametrial, uterine, and vaginal extension and tumor size
measurements than CT [8, 9]. PET/CT provides a
valuable assessment of nodal spread and distant
metastases [10, 11]. Except for the rare situation of
medically inoperable stage IA1 cervical cancer
without lymphovascular space invasion, where the
risk of extra-cervical spread is low and brachytherapy alone is indicated, external beam radiotherapy is integrated with weekly cisplatin 40 mg/
m2 (for FIGO IB2-IVA and node-positive patients)
before brachytherapy. Prolongation of total treatment duration, including external beam and
brachytherapy, beyond 8 weeks results in a
0.11 % decreases in local control and survival per
day [1215]. Thus, a detailed pelvic exam is performed in the 4th or 5th week of external beam
radiotherapy to assess response to external beam
and to prepare for the optimal timing of brachytherapy to minimize overall treatment time. This
response-based evaluation will also help to make
the final determination of the most appropriate
brachytherapy application: intracavitary, hybrid

intracavitary-interstitial, or interstitial.
For most patients, brachytherapy is completed using an intracavitary technique with
either a tandem-and-ring or tandem-and-ovoid
applicator. A tandem-and-ring applicator has the
advantages of easier placement and fixed reproducible geometry. However, in comparison to
tandem and ovoids, it can increase dose to the
vaginal surface, has less lateral throw-off of
dose, and is sometimes not suitable for patients
with a narrow vagina [16]. Compared to intracavitary applicators, a hybrid intracavitary-interstitial applicator offers the ability to increase
lateral coverage in patients with residual bulky
central or medial parametrial disease, to increase
dose to asymmetric cervical tumors, or to
decrease dose to critical organs while maintaining adequate coverage of the target volume
[1719]. While a hybrid intracavitary-interstitial
applicator can improve lateral coverage, the
range of improvement over an intracavitary
application is usually at maximum 1 cm; thus
template-based interstitial brachytherapy is the
treatment of choice for patients with residual
disease extending to the lateral parametria and
distal half of the vagina, bladder, or rectum or for
patients where the endocervical canal cannot be
located because of distorted anatomy [16].
For intracavitary brachytherapy, dilation of
the endocervical canal for tandem insertion is
required. This can either be completed under general anesthesia followed by Smit sleeve placement
at the first fraction, with subsequent applications
performed on an outpatient basis with oral analgesia or conscious sedation or with serial dilations
under general anesthesia or conscious sedation
for each fraction. Brachytherapy is usually held
should the absolute neutrophil count fall below
500 cells/l and concurrent brachytherapy on the
same day as chemotherapy is avoided to minimize
increasing the risk of normal tissue complications. The patient is placed in the dorsal lithotomy
position and a bladder catheter is placed. For difficult applications where ultrasound guidance is
used (see Fig. 1), the bladder may be filled with
saline to increase visualization of the uterus and
cervix. Prior to the procedure, the patient is given
Gynecologic Brachytherapy: Cervical Cancer
instructions for a low-residue diet to minimize

rectal distention. Rectosigmoid and bladder contrast are not necessary with MR-based brachytherapy planning, but are helpful with CT-based
planning. A sterile speculum is inserted into the
vagina to visualize the cervix. The tandem is
inserted with the angle matching the direction of
uterine flexion (with the length of the tandem
based on uterine sound measurements and prior
MRI imaging). Then the largest size ring or ovoids
the patient can accommodate are placed followed
by a rectal retractor or appropriate vaginal packing. The placement of an external stabilization
device such as a perineal bar or base plate and
clamp is then performed. Applicator placement
geometry can be confirmed on fluoroscopy or
orthogonal films or CT or MR scout films after
the patient is returned to a more neutral supine
position with thighs together, before the CT or
MR scans are obtained in the event that applicator
repositioning is needed.
Three-dimensional image-based planning
offers a number of distinct clinical advantages
over traditional two-dimensional point-based
planning: confirmation of applicator placement
including recognition of inadvertent perforation
(see Fig. 1), improved tumor coverage (see
Fig. 2), and decreased dose to critical organs (see
Fig. 2) [20]. MRI-based planning offers superior
soft tissue contrast and remains the standard for
GTV and CTV definition [21]. The benefits of
MRI over CT-based planning were highlighted
a
Fig. 1 Inadvertent uterine perforation recognized by

image-based planning and ameliorated by ultrasound
image-guided application. (a) Inadvertent perforation of
the tandem through the posterior wall of the uterus. (b)
271
by a prospective international comparison

between CT- and MRI-based brachytherapy
which showed that CT-based brachytherapy significantly overestimates the tumor width especially in the context of disease extending to the
parametria [22]. More recently, a consensus contouring atlas by gynecologic brachytherapy
experts was created comparing MRI- and
CT-based planning, again highlighting that, for
patients with a good treatment response and no
parametrial involvement, CT- and MRI-based
contouring were similar; however there was
greater variation for cases with parametrial or
sidewall extension especially those with a good
response favoring MRI-based planning [23]. If
MRI-based planning with each fraction is not
possible, alternative methods include MRI with
the first fraction and subsequent serial CT-based
planning [2426], CT-based planning [22, 27], or
ultrasound-based planning [28, 29].
Guidelines for target and organ-at-risk contouring are outlined in the GEC-ESTRO and
ABS working group consensus statements [16,
3034]. The high-risk CTV (HR-CTV) includes
the entire cervix (defined as 1 cm superior to the
insertion of the uterine arteries, to the point of
uterine widening, or a total length of
approximately 3 cm) plus any residual tumor
extension at the time of brachytherapy. The
intermediate-risk CTV (IR-CTV) includes the
HR-CTV plus the tumor extension at the time of
diagnosis. The optimization process begins with
c
Ultrasound-based image-guided replacement of the

tandem. (c) Subsequent MRI-based planning confirming
appropriate tandem placement
J.A. Vargo et al.
272
Fig. 2 Image-based brachytherapy benefits. Highlighted

by the arrows is the HR-CTV volume extending posterior
beyond the 100 % isodose line with significant unnecessary
dose to the bladder neck, which is improved with
posteriorly placed interstitial needles using a hybrid

intracavitary-interstitial applicator and image-based
manual optimization
a digitization of the source track, aided with a

CT- or MR-compatible marker placed prior to
image acquisition. Dwell positions and times are
manually optimized for each fraction aiming for
a HR-CTV D90 % 8090 Gy while limiting the
equivalent dose at 2 Gy per fraction (EQD2 Gy) to
D2 cc of the rectum/sigmoid and bladder 70 Gy
and 80 Gy. Based on prospective studies from
Korea and Vienna, if these organ-at-risk constraints are met, the risk of grade 2+ late toxicities should be <5 % [3537]. For patients with a
good response, the target HR-CTV D90 % EQD2 Gy
is 8085 Gy, while for patients with a poor
response, bulky tumors, or a histology of adenocarcinoma, dose escalation to an aimed EQD2 Gy
of 8590 Gy may improve outcomes based on
published dose response data [38, 39].
Fractionation patterns commonly used in the
United States for intracavitary brachytherapy as
outlined in the ABS guidelines are detailed in
Table 1.
For hybrid intracavitary-interstitial applications, the decision to insert needles may be
based on clinical examination or an MRI
obtained after external beam indicating significant residual disease. Alternatively, intracavitary brachytherapy can be completed for the
Table 1 Regimens frequently used in the United States

for intracavitary brachytherapy as outlined in the
American Brachytherapy Society consensus guidelines
HDR brachytheraphy dose (after
1.8 Gy 25 fractions of EBRT)
7 Gy 4 fractions
6 Gy 5 fractions
5 Gy 6 fractions
5.5 Gy 5 fractions
EQD2 Gy (/
of 10)
84.0 Gy
84.3 Gy
81.8 Gy
79.8 Gy
Gy gray, EQD2 Gy equivalent dose at 2 Gy per fraction,

HDR high dose rate, EBRT external beam radiotherapy
first fraction; should HR-CTV D90 % 100 %

coverage or critical organ dosimetry be suboptimal, then for subsequent fractions the planning
MRI for the first fraction can be used to select
interstitial needle location and depth for subsequent fractions [19]. Similar to the intracavitary
technique, MRI-based planning is used to confirm applicator and interstitial needle placement. Planning is similar to that described above
for intracavitary brachytherapy, with subsequent
additive manual optimization to supplement
missing coverage with the needles while respecting the previously described constraints for the
rectum, bladder, and sigmoid [18, 34]. To avoid
increasing mucosal dose at the needle region, on
average only approximately 10 % of the total

dwell time is linked to the needles [18, 34].
For interstitial applications, needle placement is typically performed under general or
spinal anesthesia, with an epidural anesthesia
catheter placed preoperatively in order to augment postoperative pain control. A tandem
should be placed whenever feasible, as tandem
placement is critical to maintaining adequate
HR-CTV dose and central dose inhomogeneity
[40]. To provide countertraction for needle
insertion, a series of sutures can be placed in the
cervix. Ideally needles should be placed with
1 cm spacing aiming to cover the gross disease
plus an additional 1 cm margin; the spacing and
geometry are often best maintained through the
use of a perineal template. Perineal templates
include the Syed-Neblett template or a MUPIT
applicator or institutional customized variations
[41, 42]. Titanium or plastic needles may help to
reduce CT artifact and facilitate MRI-based
planning [43]. Image guidance (either via transabdominal or transrectal ultrasound, CT, or
MRI) helps to reduce the likelihood of inadvertent needle placement in the bowel, rectum, or
bladder [4447]. Needles placed within the
bladder, rectum, or sigmoid should either be
removed or not loaded unless there is direct
extension of disease to these adjacent organs
[48]. Antibiotic prophylaxis is administered to
all patients after needle insertion. Following
needle placement, the applicator may be sutured
to the perineum to minimize interfraction displacement, and the needles are attached to the
template with an adhesive bond if necessary.
The patient is maintained on standard medical
precautions for patients requiring prolonged
immobilization including deep vein thrombosis
prophylaxis, bladder catheter placement, analgesia with an epidural catheter if feasible, and
antidiarrheal medications to prevent a bowel
movement during the implant duration. CT- or
MRI-based planning has also shown superiority
over film-based planning [16]. Upon leaving the
recovery room, a pelvic CT or MRI is completed
for image-based planning with needle adjustment as needed under epidural analgesia [49
51]. Prior to image acquisition for CT-based
273
planning, dilute contrast (3070 cc) is placed

into the bladder and 2040 cc is inserted into the
rectum. The CTV definition again follows the
GEC-ESTRO and ABS guidelines as previously
described [16, 3034]. The goal of planning is
to achieve a HR-CTV D90 % 7585 Gy while
limiting the EQD2 Gy to D2 cc of the rectum/sigmoid and bladder 70 Gy and 80 Gy, respectively. Fractionation schedules as outlined in the
ABS guidelines include 33.5 Gy times 9 fractions, 4.25 Gy times 7 fractions, or 4.55 Gy
times 5 fractions. The plan is manually optimized aiming for a CTV D90 % of approximately
7585 Gy based on the extent of disease, critical
organ doses, histology, and response to external
beam radiotherapy.
An alternative technique is to use low-dose-rate

(LDR) or pulse-dose-rate brachytherapy (PDR).
PDR brachytherapy uses a remote afterloading
192
IR source with a source strength of approximately 1 Ci (as compared to the 10 Ci 192IR
source used in HDR brachytherapy) to approximate the 0.40.6 Gy/h dose rate of LDR with
the added benefit of optimization of source
stepping and dwell times [31]. The lower dose
rate of LDR or PDR as compared to HDR may
reduce toxicity by enhancing sublethal damage
repair; however this potential radiobiological
advantage over HDR comes at the cost of
increased applicator movement during treatment [52]. Cervical cancer brachytherapy using
LDR or PDR would include all the above steps
for applicator placement and immobilization
precautions (with the added precaution of radiation exposure precautions for LDR). Typically
for intracavitary applications, LDR or PDR
brachytherapy is completed in two applications
one within 46 weeks after the initiation of
external beam radiotherapy and a second 12
weeks later, again maintaining a total treatment
time of <8 weeks. The target contouring, aimed
HR-CTV D90 %, critical organ D2 cc, and manual
optimization process remain similar to those
described above.
J.A. Vargo et al.
274

Standards
There are several American Association of

Physicists in Medicine (AAPM) task group
publications that serve as invaluable resources
for brachytherapy quality assurance; additionally
the American Society for Radiation Oncology
(ASTRO) has recently published an executive
summary [5357]. As outlined in the ABS
guidelines for intracavitary brachytherapy,
recommended documentation includes the type
of applicator, prescription (including dose per
fraction, total dose, and designated target
volume), dose to point A or other prescription
points, total reference air kerma, loading patterns,
HR-CTV D90 % D100 % V100 %, critical organ D0.1 cc
and D2 cc, vaginal mucosa dose, and isodose
distributions [16].
significantly improved local control across

subgroups (79100 % versus 7492 %, p = 0.003)
with a strong trend toward improved disease-free
survival (6090 % versus 5587 %, p = 0.086)
while more than halving the risk of toxicity
(39 % versus 1323 %, p = 0.002) as compared
to conventional 2-dimensional film-based
brachytherapy [59]. This prospective data is
further validated by three-large international
retrospective comparisons also showing a
significant reduction in toxicity and improved
local control and survival with image-based
brachytherapy when compared to twodimensional film-based brachytherapy [63, 65,
66]. Combined, these series set the standard for
modern brachytherapy in cervical cancer with
local control consistently >8090 % (even
in locally advanced disease) with the risk of
grade 3+ toxicity <510 % (see Table 2).
Results
While the integration of concurrent chemotherapy

translated into a significant improvement in
overall survival across multiple prospective
randomized trials, outcomes especially for
locally advanced cervical cancer can still be
improved [58]. However, more recently a number
of publications have shown the value of imagebased brachytherapy as the latest major
improvement in cervical cancer [27, 39, 5967].
Table 2 summarizes the outcomes of published
international experiences for modern imagebased brachytherapy with local control rates
ranging from 79 to 100 % and grade 3+
complications from 0 to 14 %. When compared
to conventional 2-dimensional brachytherapy,
3-dimensional
image-based
brachytherapy
significantly improves local control and decreases
the risk of significant morbidity. This was best
highlighted in a recently published French
prospective multi-institutional trial enrolling
>700 cervical cancer patients across 20 centers,
which compared 2-dimensional LDR or PDR
brachytherapy to modern 3-dimensional (mainly
CT-based) image-based PDR brachytherapy [59].
Three-dimensional image-based brachytherapy
Complications
and Management
Increased adoption of image-based brachytherapy

will help to reduce the risk of severe complications by more than half that are seen with
two-dimensional film-based brachytherapy; however up to 510 % will still experience severe
grade 3+ complications [59, 63, 65, 66]. The
most severe complication is rectovaginal or vesicovaginal fistulae formation, which causes significant physical, social, and psychological
distress due to persistent leakage of flatus, stool,
or urine and associated bleeding, pain, and
increased risk of infection. Management typically
includes imaging (with contrast-enhanced pelvic
MRI with water-based vaginal gel representing
the preferred modality) and exam under
anesthesia to confirm the presence of a fistula and
rule out recurrent disease [68]. While it is
important to confirm disease recurrence in the
setting of fistulae as this often directs
management, it must be recognized that mucosal
changes are common following chemoradiation
therapy and indiscriminate biopsies are a
significant precipitant of fistula formation and are
often low yield [69, 70]. Once a fistula is
275

Table 2 Summary of results for modern image-based brachytherapy in cervical cancer
STIC (2-year) [59]

Vienna (3-year) [65]
Leiden (3-year) [66]
Aarhus (3-year) [63]
Milwaukee (2 year) [62]
Thailand (2-year) [67]
Paris (4-year) [60]
Australia (5-year) [64]
Korea (3-year) [61]
Pittsburgh (3-year) [39]
Addenbrooke (3-year) [27]
Local control (Actuarial)

79100 %
95 %
93 %
91 %
100 %
98 %
91 %
8788 %
97 %
92 %
96 %
Grade 3+ late toxicity

(Actuarial)
39 %
8 %a
7 %a
7%
11 %a
4 %a
0%
15 %
1%
3%
14 %
Overall survival
(Actuarial)
7496 %
68 %
86 %
79 %
93 %
94 %
94 %
60 %
NR
77 %
82 %
NR not reported
a
Crude toxicity rate as actuarial estimate was not reported
confirmed, fecal or urinary diversion is warranted,

with the type of diversion individualized based
on patient performance status, disease status,
extent of prior radiotherapy, bowel health, and
other factors. In the absence of recurrent disease,
hyperbaric oxygen may promote fistula healing.
Less commonly complex surgical repair may be
attempted especially for vesicovaginal fistulae;
however the success rate is significantly reduced
in a previously irradiated field ranging from 40 to
100 % and must be balanced with increasing
risks of surgical complications [71, 72]. More
commonly patients may experience chronic
rectal bleeding (daily or episodic, not
uncommonly associated with incontinence or
diarrhea) as a result of radiation proctopathy. In
the era of 2-dimensional brachytherapy, the
incidence of mild to severe rectal bleeding ranged
from 5 to 30 % [73]. A retrospective cohort study
comparing image-based brachytherapy to
conventional film-based planning highlighted the
opportunity for image-based planning to reduce
the risk of rectal bleeding, where severe rectal
bleeding was documented in 2 % of patients
treated with CT-based brachytherapy as compared
to 13 % of those treated with conventional
2-dimensional brachytherapy planning, p = 0.02
[61]. For patients experiencing mild to moderate
bleeding, conservative management with
corticosteroid, sucralfate, or mesalamine enemas
is effective in >7080 % of patients [7378].
Should bleeding persist or increase in severity,

endoscopic evaluation with intrarectal thermal or
photocoagulation is the most effective means of
reducing moderate to severe bleeding [79, 80].
Vaginal stenosis remains a significant source of
morbidity with most patients (upwards of 90 %)
experiencing mild to moderate vaginal morbidity
most commonly manifested as vaginal stenosis
or dryness [81]. Dilator use remains an important
part of mitigating risks of vaginal stenosis.
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Vaginal Cancer
Abstract
Primary vaginal cancer is the rarest of gynecologic malignancies by anatomic site. Despite the rarity, vaginal cancer requires special consideration
in treatment and frequently requires brachytherapy for local control and
cure.
Introduction
Primary vaginal cancer is a rare malignancy representing <2 % of all gynecologic cancers; more
commonly vaginal cancers represent extension
from cervical or vulvar cancer, metastases, or
recurrences from endometrial, cervical, vulvar,

Department of Radiation Oncology,
University of Pittsburgh, Pittsburgh, PA, USA
e-mail: [email protected]; [email protected]
Harvard Medical School, Boston, MA, USA
Department of Radiation Oncology,
Medical College of Wisconsin, Milwaukee, WI, USA
or other primary sites. The majority (8090 %) of

primary vaginal cancers are squamous cell histology, followed by adenocarcinoma (including
clear-cell adenocarcinoma linked to diethylstilbestrol exposure in utero), melanoma, and sarcomas, respectively. Human papillomavirus (HPV,
most commonly the HPV-16 serotype) is an
oncogenic driver in 5075 % of primary vaginal
cancer, with HPV-positive vaginal cancers carrying an improved prognosis [1, 2]. Except for
highly select stage I patients, oncologic organ
preserving surgery is not feasible. Thus definitive
radiotherapy is the preferred local treatment
modality, with brachytherapy considered an integral part of definitive radiotherapy for primary
and recurrent vaginal cancers [35].
Indications
For patients with FIGO stage I disease, brachytherapy alone or in combination with external
beam radiotherapy or surgical resection represents potentially reasonable plans of care [6].

DOI 10.1007/978-3-319-26791-3_16
279
J.A. Vargo et al.
280
Otherwise for patients with FIGO stage IIIVA

primary vaginal cancer or vaginal recurrences
of other gynecological primaries, brachytherapy is commonly used to boost sites of gross
disease following concurrent pelvic chemoradiotherapy to address the at-risk intervening
lymphatics, paravaginal tissue, and regional
lymph nodes [57].
Technique
The key first step in vaginal brachytherapy

includes a pre-therapy gynecologic exam and
staging imaging commonly including a CT of
the chest, abdomen, and pelvis or full-body
PET/CT, plus a pelvic MRI with water-based
vaginal gel [8, 9]. The selection of intracavitary
versus interstitial brachytherapy depends on the
location, extent, and thickness of disease
assessed both on pre- and post-external beam
radiotherapy, wherein an exam and staging pelvic MRI with water-based vaginal gel are
extremely helpful in guiding subsequent
brachytherapy planning. Fiducial markers can
be placed at the time of exam to mark gross disease. For patients with superficial lesions
(0.5 cm in thickness on gynecologic exam following external beam radiotherapy), especially
those in the proximal or mid-vagina, intracavitary brachytherapy is commonly completed
using a single-channel vaginal cylinder or other
intravaginal applicators. The technique for
intracavitary vaginal brachytherapy has been
extensively detailed in the endometrial cancer
section including applicator placement and
planning for patients following hysterectomy.
For patients with an intact uterus, an intrauterine tandem is commonly used to improve vaginal forniceal coverage. For intracavitary
brachytherapy in patients with disease limited
to a single-wall or distal vaginal cancer, some
institutions advocate for a shielded singlechannel vaginal cylinder to minimize dose to
uninvolved vagina and critical organs (most
notably urethra and rectum); however this technique is challenged by applicator availability,
applicator weight, and non-compatibility with
image-based planning [10]. Others have advocated for the use of a multichannel intravaginal
cylinder (see Fig. 1), which may allow for
improved dose modulation over a single-channel intravaginal cylinder especially in vaginal
cancers limited to a single vaginal wall in the
middle or distal vagina [1113].
Image-based planning for vaginal cancer is
currently the preferred technique [1418].
Following intracavitary applicator placement,
image-based planning using either a T2-weighted
pelvic MRI or non-contrast-enhanced pelvic CT
is completed with each fraction. The CTV is
based on a combination of both the pre- and postexternal beam radiotherapy extent of disease
[17]. The HR-CTV includes the post-external
beam radiotherapy GTV to the residual disease
thickness and the circumference of vagina at the
level of residual disease to the vaginal surface
(see Fig. 1). The IR-CTV includes the regional of
initial tumor extension plus the remaining vagina
to account for potential microscopic submucosal
spread through intervening lymphatics [17].
Based on patterns of failure predominately in the
HR-CTV volume, others are exploring the
hypothesis that the 4550.4 Gy of external beam
radiotherapy may be sufficient to address this
microscopic disease by modifying the IR-CTV
from the entire vagina to the length of initially
involved vagina in an attempt to reduce vaginal
morbidity [14, 17]. The HDR dose and fractionation is modulated based on the extent of disease,
response to external beam radiotherapy, location
within the vagina, and dose of external beam
radiation therapy. Following 4550.4 Gy of external beam radiation therapy with concurrent
weekly cisplatin chemotherapy [19], fractionation schedules as outlined in the American
Brachytherapy Society guidelines include
45.5 Gy times 5 fractions, 3 Gy times 910 fractions, or 7 Gy times 3 fractions, though other
fractionations are feasible while respecting
organs-at-risk dose limits [20]. The plan is optimized using points in the apex, curvature of the
cylinder dome, and the lateral vaginal mucosa.
The plan is then manually optimized to cover the
contoured HR-CTV aiming for a D90 % EQD2 Gy of
75 Gy with a range of 7080 Gy as described in
Gynecologic Brachytherapy: Vaginal Cancer
281
Fig. 1 Image-based vaginal brachytherapy using a multichannel intravaginal cylinder with MRI-based planning.
The GTV at the time of brachytherapy is outlined in green.
The CTV is outlined in red, which incorporates the entire
circumference of the vagina at the level of disease to the
surface of the vaginal cylinder and the thickness of the
GTV at the time of brachytherapy. The isodose cloud

highlights that the multichannel cylinder and image-based
planning allow the dose to be extended laterally to increase
coverage of the GTV at the time of brachytherapy, the yellow cloud represents the 150 % isodose, red represents the
100 % isodose, and green represents the 80 % isodose
the American Brachytherapy Society guidelines

[20], while maintaining the rectal D2 cc <70 Gy,
sigmoid D2 cc <70 Gy, bladder D2 cc <80 Gy, and
urethral maximum dose <100 % of the prescription dose [21, 22]. No vaginal dose constraint is
implemented, though it should be recognized that
the estimated tolerance of the distal vagina
(~80 Gy) is significantly less than the proximal
vagina (~120 Gy).
Interstitial brachytherapy is recommended for
patients with disease thickness beyond the range
of a cylinder following external beam radiotherapy
and is used at some institutions for distal vaginal
cancers confined to a single wall to limit dose to
the uninvolved vagina and surrounding critical
organs [20]. Interstitial needle placement is
typically completed under general or spinal
anesthesia. Additionally, epidural anesthesia
augments pain control postoperatively and allows
for applicator adjustment based on imaging. For
patients with apical lesions, a perineal template
with a vaginal cylinder is recommended to guide
needle placement. For distal vaginal lesions,
either a free-hand or template-based technique
can be used. Ideally needles should be placed
with 1 cm spacing aiming to cover the gross disease plus an additional 1 cm margin. While traditionally steel needles were used for interstitial
brachytherapy, titanium or plastic needles may
help to reduce CT artifact and facilitate MRIbased planning [23]. Laparoscopic guidance
(especially for apical lesions in close proximity
to small bowel) or image guidance (either via
ultrasound, CT, or MRI depending on expertise
and availability) helps to reduce the likelihood of
inadvertent needle placement in the bowel, rectum, or bladder [2428]. Additionally, needle
placement within the urethra or rectovaginal septum should be avoided, unless one is intentionally attempting to place a hydrogel spacer in
between the rectum and vaginal wall or there is
tumor extending to these locations [29].
Following needle placement, the applicator may
be sutured to the labia to minimize interfraction
displacement. The patients are maintained on
standard medical precautions for patients
requiring prolonged immobilization including
deep vein thrombosis prophylaxis, Foley catheter
placement, analgesia with an epidural catheter if
feasible,
and
antidiarrheal
medications.
J.A. Vargo et al.
282
Following postoperative recovery, pelvic CT or

MRI depending on image-based planning
preference is taken with needle adjustment as
needed. To improve organ-at-risk delineation for
CT-based planning, diluted contrast 5070 cc is
placed into the bladder with 2040 cc of rectal
contrast. Needles inadvertently placed in the
bladder or rectum do not necessarily need to be
removed; however, loading in these locations
must be avoided and antibiotic prophylaxis
should be given [30]. CTV delineation includes
the pretreatment vaginal circumference length
and the gross disease at the time of brachytherapy.
Optimization points are placed within the outer
portion of the CTV volume, aiming for between
100 and 200 points with 0.51 cm spacing, and
then the plan is manually optimized aiming for a
CTV D90 % between 70 and 80 Gy modified based
on the extent of disease, location within the
vagina, and response to external beam
radiotherapy. Interstitial HDR brachytherapy is
delivered on an inpatient basis delivered twice
daily with a minimum interaction interval of 6 h
[18, 20].
An alternative technique would be to use low-dose

rate brachytherapy as described in a number of
older institutional series [3141]. Vaginal brachytherapy using LDR would include all the above
steps for applicator placement and immobilization
precautions (with the added precaution of radiation exposure precautions). Depending on external
beam radiotherapy dose, extent of disease, and
response to external beam radiation therapy, LDR
would be administered at a dose rate of
3570 cGy/h with a prescription dose between 25
and 40 Gy aiming for a total dose of 7085 Gy.

Standards
A detailed, signed prescription including the

treatment site, prescription point, total dose,
dose per fraction, fractionation, and radioiso-
tope is imperative. Prescribed dose is recorded

as D90 % for the contoured CTV, aiming for a
D90 % 100 %. We recommend that the critical
organ doses be carried across brachytherapy
fractions and incorporate any external beam
radiotherapy dose, using an EQD2 Gy calculator,
aiming for the rectal D2 cc 70 Gy, sigmoid D2 cc
70 Gy, and bladder D2 cc 80 Gy. There are
several AAPM task group publications that
serve as invaluable resources for brachytherapy
quality assurance [4245].
Results
A number of recent institutional series have

documented high rates of local control (92
96 %) and low rates of toxicity (223 %) when
incorporating image-based brachytherapy for
primary vaginal cancer [14, 1618]; however,
the majority of outcome data for brachytherapy
in vaginal cancer comes from series examining
the role of definitive radiation therapy as a salvage modality for patients with vaginal recurrence of endometrial cancer. Table 1 highlights
the results of numerous institutional series
using a combination of external beam radiation
therapy and LDR brachytherapy for vaginal
recurrence of endometrial cancer highlighting
that definitive radiation therapy, including
brachytherapy, salvages approximately 50 %
of patients with vaginal recurrence of endometrial cancer with published 5-year overall surTable 1 Summary of clinical outcomes for two-dimensional
LDR brachytherapy plus external beam radiotherapy salvage
for vaginal recurrence of endometrial cancer
Jhingran et al. [34]

Currant et al. [35]
Lin et al. [36]
Sears et al. [37]
Hoekstra et al. [38]
Wylie et al. [39]
Jereczek et al. [40]
Morgan et al. [41]
n
91
47
50
45
26
58
73
34
Local control
(%)
75
48
74
54
84
65
48
85
5-year
overall
survival (%)
43
31
53
44
44
53
25
68
283
vivals ranging from 25 to 68 % and local control

of 4885 % [3441]. Table 2 summarizes the
results for HDR brachytherapy for vaginal recurrence of endometrial cancer, highlighting the
importance of image-based planning where the
rates of local control are similar across the pointbased and image-based series ranging from 74 to
100 % [4648]; however, grade 3+ toxicity in
series incorporating image-based planning
ranges from 0 to 5 % compared to 550 % for
series using two-dimensional point-based planning [15, 16].
Complications
and Management
As highlighted in Table 2, the major toxicity

following definitive radiation therapy for vaginal cancer, including vagina brachytherapy, is
vaginal stenosis or other toxicity such as ulceration, for which the use of modern radiation
planning techniques including image-based
brachytherapy can help to reduce such toxicity.
Similar to the description in the cervix brachy-
therapy section, a vaginal dilator is recommended to maintain patency of the vagina by

disrupting the formation of adhesions and
fibrous tissue. For patients who develop vaginal
ulceration, initial management with hydrogen
peroxide douching (1/10 dilution with water)
intravaginally one to two times per day for 24
weeks can aid healing. While rare, patients who
suffer persistent vaginal ulceration or necrosis,
hyperbaric oxygen therapy should be considered as small series have shown high rates of
resolution both for vaginal ulceration and vaginal ulceration in association with rectovaginal
fistula [49, 50]. Additionally, Trental (400 mg
tid) can also aid in healing necrotic vaginal tissue. Chronic toxicities and management for rectal and bladder injury are reviewed extensively
in the cervical cancer brachytherapy section. A
comprehensive discussion of the management
of complication following pelvic radiation therapy is beyond the scope of this text, and for
additional information the reader is directed to a
recently published dedicated review of complication following pelvic radiotherapy including
brachytherapy [51].
Table 2 Summary of clinical outcomes for HDR brachytherapy (including image-based planning) plus external beam
radiotherapy salvage for vaginal recurrence of endometrial cancer
n
22
Petignat et al.
[46]
Pai et al. [47]
20
Sorb et al. [48]
40
Image-based HDR
Vargo et al. [15] 41
Lee et al. [16]
31b
Technique
4-field EBRT
2D HDRB
4-field EBRT
2D HDRB
4-field EBRT
2D HDRB
CR (%)
100
IMRT 3D-based
HDRB
4-field EBRT
3D-based
HDRB
93 %
90
92
NR
LC
100 %, 5
years
74 %, 10
years
75 %, 5
years
95 %, 3
years
94 %, 2
years
Vaginal
Bladder
Gastrointestinal
toxicity (%) toxicity (%) toxicity (%)
50
0
18
0
19a
11
IMRT intensity modulated radiotherapy, 3D three-dimensional, 2D two-dimensional, HDRB high-dose rate

brachytherapy, NR not recorded, GI gastrointestinal
a
19 % grade 23 vaginal toxicity
b
Results for the 31 patients not receiving prior radiotherapy, local failure from this series in re-irradiation cohort was
39 % with a 23 % rate of grade 3 complications
284
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Cancer
120:38703883
Image Guidance in Gynecologic
Brachytherapy
Patrizia Guerrieri and Bryan C. Coopey
Abstract
This chapter is a practical guide for image-guided high-dose-rate (HDR)

brachytherapy in gynecologic cancers treated definitively with radiation
therapy. It will focus predominantly on the use of intracavitary brachytherapy with either ring and tandem or tandem and ovoid devices since this
is the most frequent scenario, but it will also give a brief example of an
interstitial implant. It is intended as a practical checklist, especially useful for someone who wants to implement his/her practice with a focus in
gynecologic oncology. The theoretical background and techniques are discussed extensively elsewhere in this book.
Introduction
Image-guided brachytherapy is defined by the

use of imaging to define the gross tumor volume
(GTV) of brachytherapy, which is usually the
residual tumor at time of the implant, as well as
the areas at risk for microscopic involvement
known as the high-risk CTV (HR-CTV).
Clinical examination is an important step for
evaluation of the areas that should be addressed
by brachytherapy at the time of the implant. As
P. Guerrieri, MD, MS (*)
Department of Radiation Oncology, Allegheny Health
Network, Temple University of College of Medicine,
B.C. Coopey, MS
Department of Radiation Oncology, Allegheny Health
well, images from different diagnostic studies

should be reviewed and the imaging importance
should not be underestimated. According to the
aim of the chapter as a practical guide for correct planning of gynecological brachytherapy,
and in view of the fact that clinical tumor evaluation at diagnosis and its modification during
treatment are part of the definition of HR-CTV
as defined by the GEC-ESTRO-ABS guidelines, we will begin from the point where the
patient is first seen by the radiation oncologist.
We will describe the role and use of imaging
(especially MRI) to guide the contouring of the
brachytherapy target and of the organs at risk
(OARs).
Finally, we will discuss dosimetric planning
of the implant basing our discussion on dose prescription and constraints as recommended by the
ABS-GEC-ESTRO guidelines.

DOI 10.1007/978-3-319-26791-3_17
287
P. Guerrieri and B.C. Coopey
288
Clinical Algorithm
1. Initial evaluation
Pelvic examination:
(a) Inspection, including bimanual and rectovaginal palpation
(i) Tumor dimensions
(ii) Vaginal involvement +/
(iii) Parametrial involvement +/
(iv) Vaginal size and pliability
Imaging data
Pelvic MRI (T1 with contrast and T2-weighted
images) to evaluate:
(i) Circumferential extension
(ii) Parametrial extension
(iii) Bladder involvement
(iv) Rectal involvement
(v) Vertical extension into the vagina
(clinical assessment may be more
reliable)
PET/CT
(i) To evaluate the presence of metastatic
disease
(ii) To evaluate the metabolic activity of
primary tumor/lymph nodes
2. During and at the end of pelvic radiation
therapy
Pelvic examination: inspection and rectovaginal palpation to evaluate and determine:
Tumor response to chemoradiation in terms
of:
(i) Residual tumor size
(ii) Vaginal involvement response
(iii) Parametrial involvement response
(iv) Vaginal size and pliability
(v) Anatomy of the cervix, fornices, and
vagina
3. Prior to first implant
Pelvic MRI (T2-weighted images):
(i) To evaluate and contour shape and size of
residual tumor
(ii) To evaluate circumferential extension:
parametrial,
bladder,
or
rectal
involvement
(iii) To evaluate clinical vertical extension
into the vagina (clinical assessment is
better in this situation)
(iv) For OAR contouring
Pelvic CT
(i) To fuse with MRI images for OAR
contouring
4. Post-implant
Pelvic CT
(i) For OAR dosimetry and constraints
Pelvic MRI (T2-weighted images):
(i) To evaluate and contour shape and size of
residual tumor
(ii) To evaluate circumferential extension:
parametrial,
bladder,
or
rectal
involvement
(iii) To evaluate clinical vertical extension
into the vagina (clinical assessment is
better in this situation)
(iv) For OAR contouring
Integrated image evaluation to determine:
(i) Does the patient need a parametrial
boost?
(ii) Does the patient need a pelvic lymph
node boost?
(iii) Summation of pelvic dose contribution
from different techniques.
5. Follow-up
A protocol must be set to determine when to
schedule:
(i) PET/CT
(ii) Clinical evaluation
(iii) Consideration for salvage surgery
Cervical Cancer Consultation
Together with the history and physical examination, it is important to review all referring physicians notes, pathology report, and available
staging studies. It is recommended to have a full
pelvic MRI with and without contrast and consider
infusing water-soluble aqueous gel into the vagina
to better appreciate the possible involvement of the
parametria, rectum, bladder, or vagina. These will
be important pieces of information when planning
for the implant (Figs. 1, 2, and 3). A PET/CT
should also be part of the staging to evaluate the
presence or absence of metastatic disease and to
plan for the external beam portion of the treatment.
Also, it is of importance for the brachytherapy
planning, since the possible FDG avid nodes will
Gynecologic Brachytherapy: Image Guidance in Gynecologic Brachytherapy
289
Fig. 3 Initial presentation of locally advanced cervical

cancer (coronal T2 MRI image)
Fig. 1 Sagittal MRI initial presentation of locally

advanced cervical cancer (T2 image)

cancer (PET/CT image of the primary tumor)

cancer (axial DWI MRI image)
be contoured and the necessity for a final boost

dose will be evaluated in consideration of the
brachytherapy contribution to the composite plan
(Figs. 4 and 5). This is particularly important when
delivering brachytherapy with HDR as compared
to LDR because of the different dose falloffs at the
periphery of the implant.
An essential part of the consultation will be
the planning of an examination under anesthesia
in conjunction with the gynecologic oncologist.
Among other things this will allow staging
according to the FIGO classification. It will

cancer (PET/CT image of nodal involvement)
accomplish visualization of bladder and rectal

mucosa through cysto-proctoscopy and allow for
a better appreciation of parametrial and vaginal
290
involvement. Keeping in mind the initial clinical

presentation will help in planning the brachytherapy implant at the time of boost. There is now a
tendency to shy away from EUA in favor of MRI
and this has some advantages; however, clinical
evaluation of the vagina, rectum, or bladder is
more accurate when coupling images with clinical data. The EUA and MRI should be thought of
as complimentary necessities. A further advantage of the EUA is the possibility of placing fiducial markers at the most caudal aspect of the
tumor to facilitate external beam planning.
However, we should consider that moving toward
MRI image-guided brachytherapy could make
placement of cervical fiducials for brachytherapy
unnecessary and they could possibly be
detrimental to MRI image quality.
During EUA and standard pelvic examination,
particular attention must be given to the
following:
Size of the cervix/tumor, extension into the
parametria: Does the tumor involve the pelvic
sidewall?
The vaginal fornices: Are they involved by
tumor?
Size and pliability of the vagina: Will it
accommodate easily a ring and tandem or an
ovoid and tandem device?
Extension into the vagina: Which part of the
vagina is involved? Remember that all vaginal
walls must be examined turning the speculum
90, especially when using a metallic
speculum!
Which diameter of the cervix is the largest (in
cm), anteroposterior, latero-lateral, or
craniocaudal?
Is there any gross involvement of the bladder
or rectum?
Specic Clinical Issues
4.1
Extension into the Parametria
Extensive involvement: This situation is unlikely to

be managed by a purely endocavitary brachytherapy treatment, since even in case of a good response
to concurrent chemoradiation, some gross tumor
extension into the parametria might still exist with a

consequent need to treat that portion with brachytherapy. That residual disease might be addressed
with a pure interstitial implant or with a combination of endocavitary/interstitial implant. Such a
combined approach has been made possible by the
availability of applicators such as the Vienna or
Utrecht that allow the insertion of needles into the
proximal part of the parametria through the ring
(Vienna) or ovoids (Utrecht).
4.2
Gross Involvement
of the Vagina
Unless there is involvement of only the first 2 cm

of the proximal vagina, one is unlikely able to
manage gross extension into the vagina with
classic applicators like a ring and tandem or
ovoids and tandem following chemoradiation.
Two different clinical scenarios are possible at
the time of the implant:
1. Complete response or nearly complete
response of vaginal disease at time of implant:
If the residual tumor is less than 0.5 cm in
thickness, one should plan to deliver at least
part of the treatment via a vaginal cylinder
together with an intrauterine tandem to treat
distal microscopic disease. Unfortunately, this
technique is based on a single radioactive
linear dosimetry, and dose optimization is
therefore limited by the size of the cervix, the
dose to the vaginal mucosa, and the dose to
the rectum and bladder. It is not possible to
optimize the shape of the isodoses that, in this
case, resemble a cylinder.
2. Residual vaginal tumor is more than 0.5 cm in
thickness or the vagina is very narrow: The
patient may be better served with an interstitial
implant via a Syed-Neblett or a MUPIT
template that allows treatment of the vagina
and the parametria, if necessary, along with
the cervix. The same is true in the presence of
a narrow vagina that cannot accommodate a
standard size ring and tandem. In this situation,
mini-colpostats could be a possible valid
alternative, but the dosimetry, even if
optimized, may not be so favorable, and the
risk of important side effects like rectovaginal

fistulas is higher.
We have already anticipated some issues that
must be taken into account at the time of the
implant, to stress the need to properly plan
brachytherapy since the beginning of treatment
planning and optimizing ahead the proper
integration of treatment different steps. These
aspects and issues will be reviewed later.
Imaging Considerations
5.1
Pretreatment MRI: What Is It

for and How to Use
the Findings
MRI is not part of the FIGO staging for cervix

cancer, but it is an important part of the overall
treatment planning for several reasons:
1. Parametrial extension discovered at MRI will
question the feasibility of surgery (calling for
an upfront chemoradiation treatment), since
parametrial infiltration represents one of the
high-risk factors assessed by Peters in the
GOG 109 trial [1] and will require treatment
with adjuvant concurrent chemoradiation.
2. Clinical vaginal extension can be confirmed
or sometimes discovered at MRI. This will
once again question the feasibility of immediate surgery because of the high risk of tumor
cut-through. Staging MRI will also establish baseline data for evaluating vaginal tumor
response and to discern whether or not there
may be a need to address residual vaginal disease at the time of the implant. MRI images
may also guide in identifying the caudal extent
of the external beam fields.
3. Bladder or rectal involvement on MRI will not
change the FIGO staging of the disease in the
absence of positive bladder or rectal biopsies,
but it might favor the use of an interstitial
implant to adequately treat gross tumor extension anteriorly or posteriorly.
4. MRI may identify nodal involvement not otherwise appreciated on CT. Although nodal
involvement is not part of the FIGO staging
291
system, it is an essential part of the TNM and,

together with PET and CT, will determine the
need to plan IMRT treatment especially for
the para-aortic nodes or the use of a
simultaneous boost to other involved nodes.
This last point is of importance to brachytherapy, especially if HDR brachytherapy is to be
used. Pelvic lymph nodes in proximity of the
implant will receive a sizable dose contribution
from the implant itself that needs to be taken into
account in a composite plan to avoid overdosing
OARs and therefore increasing the risk of important side effects. For lymph node treatment in
these areas, it is better to plan the boost with ERT
after the implant following an accurate evaluation
of the composite isodoses (Figs. 1, 2, and 3).
5.2
PET/CT
The role of this critical modality is to identify

occult disease that may change the treatment
intent and/or to evaluate the metabolic activity of
the tumor cells in the primary site and nodal
disease. It will also help in designing the external
beam as well as the brachytherapy targets. It will
finally be part of the evaluation of the final
response to treatment (Figs. 4 and 5).
Upon completion of staging, the patient will
be ready to start treatment, usually concurrent
chemoradiation to the pelvis (+/para-aortic
nodes), with weekly cisplatin. During
chemoradiation, a weekly on-treatment visit must
be done. This will allow both for early detection
and treatment of acute adverse events, as well as
for adequate implant timing and proper
brachytherapy technique choice.
Finalized Brachytherapy
Planning During the Course
of Concomitant
Chemoradiation
Weekly pelvic examinations should begin no

later than the third week of treatment to determine
the ideal time to initiate brachytherapy during the
course of the external beam radiotherapy (ERT),
292
especially if HDR will be used. An earlier

brachytherapy start will allow for a shorter
overall treatment time, potentially increasing the
local control rate. With HDR, only 1 fraction/
week should be administered during external
beam (not on chemotherapy days). In addition,
ERT will be held. An anatomic complete
assessment of the vagina and cervix and the
tumor size and shape will determine the feasibility
of an earlier implant and will help in the choice of
the ideal brachytherapy technique. Vaginal
accommodation and symmetry, cervix size and
distortion along with patency of cervical canal,
and forniceal and parametrial infiltration must be
attentively determined to select the best technique
and device. If desired, a cervical sleeve can be
placed by the gynecologic oncologist to facilitate
the positioning of the device on an outpatient
basis.
Finalized Brachytherapy
Planning Following
Concomitant
Chemoradiation
Should the anatomy remain unfavorable for an

intercurrent implant during chemoradiation, then
the entirety of brachytherapy should be performed
upon completion of EBT, keeping in mind that it
is imperative that all therapy be completed within
8 weeks of initiation to maximize local control
and survival [2, 3]. To meet that timeline,
brachytherapy must be started immediately
following completion of chemoradiation, using
an appropriate fractionation schedule. Several
fractionation schedules have been proposed by
the American Brachytherapy Society (ABS) [4].
Fig. 6 Locally advanced cervical cancer at first brachytherapy fraction (sagittal T2W MRI image with device in
site highlighting of the residual tumor)
Brachytherapy Schedule
At our institution, we use 5 fractions of 5.5 Gy,

two times per week. We use a cervical sleeve
that is placed by the gynecologic oncologist, to
allow outpatient brachytherapy treatment without subsequent need of general anesthesia in
most cases. At the time of sleeve placement, the
Fig. 7 Locally advanced cervical cancer at first brachytherapy fraction (axial T2 MRI image with device in site.
Residual tumor is highlighted)
patient is further evaluated while under sedation

to clinically appreciate the residual tumor. A
MRI is performed with the first brachytherapy
implant. This MRI is performed on with the
applicator in place. To minimize imaging time,
only a limited series is performed. We image
three orthogonal planes oriented with the applicator. Each plane is acquired with T2 turbo spin
echo (TSE) sequence, small field of view (FOV),
and 0.3 cm slice thickness with 0.06 cm gap
(Figs. 6, 7, and 8).
A CT scan is done for every brachytherapy
fraction. The first is fused with the MRI done at
293
placed distally to the cervix will not effectively contribute to the primary dose.
Errors in the correct positioning of the brachytherapy device are responsible for unwanted
areas of very high dosage and a suboptimal
implant with consequent increase in side effects
and potential decrease in local control.
Fig. 8 Locally advanced cervical cancer at first brachytherapy fraction (coronal T2 MRI image with device in
site and highlighting of the residual tumor and HR-CTV)
the time of first implant. Evaluation of the following is done on 3D reconstructed images:
1. The position of the tandem within the uterine
cavity. The tandem should span the entire cavity length and to fit well into the sleeve when
used.
2. The position of the tandem with respect to the
pubic symphysis and the sacral promontory.
The tandem usually sits1/2 to 2/3 of the way
toward the pubic symphysis. It should not be
too close to the sacrum to avoid undue irradiation to the bone. The position of the tandem
might have an impact on the OAR dose, since
a forward position will give more dose to the
bladder, while a backward position will contribute preferentially to the dose to the rectum
and sigmoid.
3. The geometric relationship of tandem and
ring. A tandem that is not centered within the
ring usually means that the connection
between ring and tandem has been lost.
4. The geometric relationship of tandem and
ovoids. Ovoids are positioned immediately
below the flange, and the tandem is centered
between the ovoids in the coronal and sagittal projections. A loss of symmetry in the
coronal plane means more doses to the vaginal wall closer to the tandem, while ovoids
not centered with respect to the tandem and
Target Denition in
Gynecologic Brachytherapy
In the 3D-CRT era, brachytherapy is shying

away from the 2D parameters historically used
for dose prescription, e.g., points A and B and
maximal point dose to the rectum and bladder.
While 2D parameters are still used for dose
reporting, they frequently do not accurately
reflect the dose to the tumor and the OARs.
Some of the traditional Manchester dosimetry
points are recorded, but the prescribed dose
delivered is a volume isodose.
Three-dimensional volume-based brachytherapy now uses volumes and DVH according to the
GEC-ESTRO-ABS guidelines. These define several target volumes that must be taken into account
such as high-risk CTV, intermediate-risk CTV, and
different sub-volumes of the following OARs,
bladder, rectum, sigmoid, and small bowel, with
the most useful sub-volumes being the high-risk
CTV for dose prescription and the dose to 2 cc of
the OARs for dose constraints. They represent the
parameters to which one must conform brachytherapy plans. While a full technical discussion of
these issues is not part of this chapter (please refer
to the previous chapter and to the numerous publications present in the literature), we will illustrate
how to use these concepts in clinical practice
[57].
The high-risk CTV of GYN brachytherapy is
related to the extent of GTV at time of
brachytherapy. It keeps in mind the tumor extent
at diagnosis, to gauge areas at risk of microscopic
disease, but has the intent of delivering a high
total dose (8090 Gy) to the residual tumor (highrisk CTV). The dose is comparable to the dose to
point A but is prescribed to a volume rather than
294
to a point. This volume includes the whole cervix

and the presumed tumor extension as outlined by
clinical assessment and the evidence of residual
gray zones on T2-weighted MRI images (Figs. 6,
7, and 8) [8].
10
Brachytherapy Procedure
With the sleeve in place, the patient is put in

stirrups for the positioning of the brachytherapy device. Usually lorazepam and ibuprofen
are enough to keep the discomfort of the procedure under control. A urinary catheter is put in
place and the vagina is once again examined to
choose the right size of ovoids or ring. There
are in fact, several caps that can be chosen to
accommodate the vaginal width. The largest
one that fits the patient anatomy is chosen to
better spare the OARs from unnecessary dose.
For ring and tandem combinations, the tandem
is chosen on the basis of the natural position of
the body of the uterus and ideally spans the
entire uterine cavity. The most used tandem
angles are usually 60 or 45 and the most used
length is 6 or 8 cm. Many HDR tandem and
ovoid kits carry either the straight or the curved
tandem. Curved tandems are usually chosen,
and then a flange is screwed in position according to the length of the intrauterine part of the
tandem, so that it will abut the cervical os when
positioned.
A rectal retractor is finally positioned along
the posterior wall of the vagina to displace the
anterior wall of the rectum from the high dosage
area. Alternatively, one or two vaginal balloons
can be attached to the ring or the ovoids to act as
vaginal packing. We find it difficult to do adequate
vaginal packing with contrast-soaked gauze in an
outpatient setting and prefer the use of balloons
or rectal retractors.
The MRI images are registered to the planning
CT in the treatment planning software. Since the
three orthogonal series are in the same coordinate
space, one registration co-registers all series.
Thus, contouring that is only performed on the
axial CT slices can be viewed on higherresolution images for the sagittal and coronal
reconstruction.
11
Brachytherapy Planning
After fusing the MRI images with the simulation

CT, we contour the high-risk CTV using MRI
images, while OARs are contoured on CT images
to allow for an easier comparison with CT images
obtained for the subsequent treatments. The
OARs contoured on CT are compared with MRI
images and necessary adjustments are done prior
to the first brachytherapy plan. Alternatively, an
MRI could be done for each single HDR treatment
with contouring each time of the target and OARs
on the MRI alone [9]. Current treatment planning
systems do not calculate dose with heterogeneity
corrections. The dose calculation is based on the
geometry of the sources and the AAPM Task
Group 43 (TG43) formalism. Therefore, CT is
not strictly necessary for dosimetry.
Organs at risk (OARs) are contoured in their
entirety for DVH purposes, for it has been proven
that contouring just the wall of the organ is more
subjective and less accurate [10].
The bladder is usually scanned with the urinary catheter open, therefore voiding urine, but
it can be scanned with a modest amount of water
or saline solution in it to space out possible
bowel loops from close proximity to the device.
At this time it is possible to develop a rough
treatment plan having in mind the dose to point
A as a baseline dosimetry. At our institution, we
then follow by contouring the cervix and the
residual tumor on the fused MRI images and
look at the dose to the HR-CTV as well as at the
2 cc OAR volumes. At this point, the prescription isodose is optimized according to the shape
of the HR-CTV as delineated on the MRI and as
clinically appreciated at the time of the sleeve
insertion, and the dose is modulated to meet
OAR constraints (Figs. 9, 10, and 11). An appropriate analogy would be to imagine the inflation
of a large balloon in the center of a room. The
balloon needs to be inflated as large as possible
without hitting the walls, floor, or ceiling. The
necessary volume of this balloon is the contoured volume of the HR-CTV. The ceiling
height and wall distances are the 2 cc OAR dose
limits. From one fraction to the next, the ceiling
height (bladder proximity and size) may
decrease. The balloon can be squeezed in a
Fig. 9 Locally advanced cervical cancer at first brachytherapy fraction (dosimetric coronal reconstruction of the
first treatment on fused T2W MRI image)
Fig. 10 Locally advanced cervical cancer at first brachytherapy fraction (dosimetric coronal reconstruction of the
first treatment on CT image)
different direction (increasing dwell times in

ring or tip of tandem) to keep the same volume
but not hit the ceiling. According to GECESTRO-ABS guidelines, the dose of 2 cc for the
bladder, rectum, and sigmoid should be kept at
less than 80 % of the prescription dose. For the
rectum and sigmoid, we tend to stay between 60
and 80 % of the prescribed dose, and we monitor bowel in proximity to the implant. We prefer
small bowel D2cc equal to 60 % of the prescribed dose but know that the small bowel
loops can shift around between scanning and
treatment and between individual treatments;
therefore, we review the total D2cc from the
entire brachytherapy treatment preferentially
over each individual fraction dose. Of course,
our priority is to give a meaningful dose to the
tumor to maximize local control. Again according to GEC-ESTRO-ABS, the composite dose
to the HR-CTV should be between 80 and 90 Gy
EQD2, according to primary tumor volume.
In addition to the 2 cc OAR doses, the traditional Manchester calculation points of Pt A and
Pt B are calculated on every case. These points
can serve as a prescription surrogate to the 3D
volume prescription in cases where HR-CTV
contouring is not possible. These points also
serve as a bridge from the old brachytherapy
methods to the new.
Another parameter that is recorded on every
case is the source activity (Ci) multiplied by the
treatment time in seconds (s). The resulting Ci*s
value is fairly constant depending on prescription
dose and tandem length. The Ci*s varies little
between individual fractions on each patient.
A fractionation schedule of 5.5 Gy 5 is
equivalent to 8590 Gy EQD2 when combined to
4550 Gy of pelvic external beam, and we follow
the OAR constraints recommended by the
GEC-ESTRO-ABS guidelines [7]:
Bladder D2cc
Rectum D2cc
Sigmoid D2 cc
Small bowel D2cc
Fig. 11 Locally advanced cervical cancer at first brachytherapy fraction (dosimetric sagittal reconstruction of the
first treatment on fused T2 MRI image)
295
80 Gy EQD2
7075 Gy EQD2
7075 Gy EQD2
60Gy EQD2
We also report the dose to 0.1 cc and value

D0.1 cc since it is a representative expression of
the maximal dose.
296
Fig. 12 Locally advanced cervical cancer: dosimetric reconstruction of composite dose from external and intracavitary
brachytherapy with highlighting of a small PET positive node
12
Dosimetric Evaluation
of the Dose Contribution
from External Beam
and Brachytherapy
At the end of brachytherapy, especially when

there is an initial finding of gross parametrial
involvement or evidence of pathologically
involved pelvic lymph nodes, it is recommended
to evaluate the dose received by the involved
parametrium or lymph nodes through combined
external and brachytherapy doses. At our institution, we use software to add each fractions 3D
dose to form a composite dose distribution. This
composite dose is combined with the 3D dose
calculation from the external beam dose. This
way we can better evaluate the composite dose to
the organs at risk. HDR brachytherapy usually
gives a contribution of 68 Gy to the distal part of
the parametria, therefore microscopic parametrial disease or a small lymph node might not
require additional boost dose (Fig. 12).
13
Gross residual parametrial or vaginal tumor cannot be treated with a simple endocavitary treatment with ring and tandem or tandem and ovoids
in some cases and may require an interstitial
implant with a Syed-Neblett or a MUPIT template (Fig. 13); however, the technical explanation of this type of implant goes beyond the scope
of this chapter. Suffice it to say that these are
more complex implants that can cause a higher
risk of significant permanent adverse events and
should be therefore carried out in centers with
extensive clinical experience.
Fig. 13 Locally advanced cervical cancer at first brachytherapy fraction (dosimetric axial reconstruction of the
interstitial treatment on fused T2 MRI image)
14
Follow-Up
Follow-up appointments and their timing are

important factors that would allow (1) to follow
tumor response to treatment, (2) detect important
side effects, and (3) assess the need for possible surgical intervention or complication management.
Response to treatment is best evaluated by
clinical examination and by a PET/CT at 23
months from the end of the treatment. A complete disappearance of the FDG avidity at that
point represents a positive prognostic factor [11].
It may take months for the tumor to completely resolve, and sometimes the tumor is
replaced by a necrotic process that takes a long
time to heal. It is important in this situation to
decide timing and opportunity of a biopsy to clarify the issue of tumor necrosis or tumor senescence versus tumor progression or relapse.
Salvage surgery or surgical intervention to
symptomatically improve side effects like bowel
stenosis and bladder or rectal fistula formation
may be necessary, and close collaboration and
communication with the surgeon are necessary.
References
1. Peters WA et al (2000) Concurrent chemotherapy and
pelvic Radiation Therapy compared with pelvic
Radiation Therapy Alone as adjuvant therapy after
297
Radical Surgery in High-Risk Early-Stage cancer of

the cervix. J Clin Oncol 18(8):16061613
2. Gasinska A, Fowler JF, Lind BK et al (2004) Influence
of overall treatment time and radiobiological parameters on biologically effective doses in cervical cancer
patients treated with radiation therapy alone. Acta
Oncol 43(7):657666
3. Mandal A, Asthana AK, Aggarwal LM (2007) Clinical
significance of cumulative biological effective dose
and overall treatment time in the treatment of carcinoma cervix. J Med Phys 32(2):6872
4. Nag S, Erickson B, Thomadsen B et al (2012) The
American Brachytherapy Society recommendations for
high-dose-rate brachytherapy for carcinoma of the cervix. American Brachytherapy Society. Brachytherapy
11(1):4752
5. Haie-Meder C, Ptter R, van Limbergen E (2005)
Recommendations from the gynaecological (GYN)
GEC-ESTRO working group: concepts and terms in
3D image based 3D treatment planning in cervix
cancer brachytherapy with emphasis on MRI assessment of GTV and CTV. Radiother Oncol 74:
235245
6. Hellebust TP, Kirisits C, Berger D (2010)
Recommendations from Gynaecological (GYN)
GEC-ESTRO working group: considerations and
pitfalls in commissioning and applicator reconstruction in 3D image-based treatment planning of
cervix cancer brachytherapy. Radiother Oncol
96:153160
7. Ptter R, Haie-Meder C, van Limbergen E (2006)
Recommendations from gynaecological (GYN)
GEC-ESTRO working group (II): concepts and
terms in 3D image-based treatment planning in cervix cancer brachytherapy-3D dosevolume parameters and aspects of 3D image-based anatomy,
radiation physics, and radiobiology. Radiother
Oncol 78:6777
8. Dimopoulos JCA, Petrow P, Tanderup K et al (2012)
Recommendations from Gynaecological (GYN)
GEC-ESTRO Working Group (IV): basic principles
and parameters for MR imaging within the frame of
image based adaptive cervix cancer brachytherapy.
9. Gill BS, Kim H, Houser CJ et al (2015) MRI-guided
high-dose-rate intracavitary brachytherapy for treatment of cervical cancer: the University of Pittsburgh
experience. Int J Radiat Oncol Biol Phys
91(3):540547
10. Yaparpalvi R, Mutyala S, Gorla GR et al (2008)
Point vs. volumetric bladder and rectal doses in combined
intracavitary-interstitial
high-dose-rate
brachytherapy: correlation and comparison with
published Vienna applicator data. Brachytherapy
7(4):336342
11. Grigsby PW, Siegel BA, Dehdashti F et al (2003)
Post-therapy surveillance monitoring of cervical cancer by FDG-PET. Int J Radiat Oncol Biol Phys
55:907913
Prostate: Low Dose Rate

Brachytherapy
Pei Shuen Lim and Peter Hoskin
Abstract
Brachytherapy has the advantage of delivering a high tumoricidal dose of

radiation to the target volume, while giving low doses to the surrounding
normal tissues as dose falloff obeys the inverse square law. It therefore
offers an elegant means of treating prostate cancer avoiding the anatomical
disruption of major surgery or the more widespread radiation effects
associated with external beam therapy.
Introduction
Prostate cancer is increasing in incidence annually

in the USA and Europe with well over one million
men diagnosed each year. In the UK it is now the
most common cancer in men and accounts for a
quarter of all male cancers. The highest incidence
worldwide is seen in Australasia with 115 per
100,000 new cases per year. This compares with
98 per 100,000 in the USA and 73 per 100,000 in
the UK. Low incidence is seen in Africa and Asia
with incidence rates of 31 per 100,000 in Nigeria
and Kenya and only 4 per 100,000 in India [1].
P.S. Lim, BM, MRCP
Specialist Registrar in Clinical Oncology, Mount
Vernon Cancer Centre, Northwood, UK
P. Hoskin, MD (*)
Consultant in Clinical Oncology, Professor,
Mount Vernon Cancer Centre and University College
Northwood, London, UK
In those areas with high incidence, much of the

increase can be accounted for by earlier diagnosis
using PSA measurements in relatively asymptomatic men together with an aging male population.
The majority of these men will present with localized low- to intermediate-risk prostate cancer and
be candidates for active surveillance, radical prostatectomy, or brachytherapy. Death from prostate
cancer in this group is unlikely whichever treatment is used and therefore with the prospect of
many years of life ahead dealing with the legacy
of treatment an informed decision is critical.
Low Dose Rate Prostate

Brachytherapy
2.1
Indications
and Contraindications
Patients can be considered for LDR brachytherapy if they have localized prostate cancer without

DOI 10.1007/978-3-319-26791-3_18
299
P.S. Lim and P. Hoskin
300
metastases and a life expectancy of longer than

10 years. Patients can broadly be stratified into
different risk groups based on three main prognostic factors: Gleason score, PSA value, and T
stage. The American Brachytherapy Society
(ABS) recommends using the National
Comprehensive Cancer Network guidelines
classification [2]:
Low risk Gleason score 6 and PSA <10 ng/mL
and T1-T2a tumor
Medium risk Gleason score 7 or PSA
1020 ng/mL or T2b-T2c tumor
High risk Gleason score 810 or PSA
>20 ng/mL or T3a tumor
Guidelines by the ESTRO/EAU/EORTC with
recommendations on patient selection for LDR
brachytherapy are shown in Table 1 [3]. Those
predicted to have a poor outcome should be
considered for other modalities of treatment or
combination treatment.
When selecting patients, it is important to
consider the functional outcome as well as the
oncological outcome after treatment. A high
International Prostate Symptom Score (IPSS)
and low flow rate (Qmax) pretreatment are related
to an increased risk of catheter use and irritative
urinary morbidity post implant [4]. Patients with
an IPSS score of more than 20 have been found to
have a higher risk of prolonged urethritis and
urinary retention [5,6].
A large gland has a higher probability of pubic
arch interference where part of the prostate sits
behind the bone and physically does not permit a
geometrically satisfactory implant. It is
recommended that patients with glands larger
than 5060 cm3 should undergo a few months of

antiandrogen therapy, which normally results in a
30 % volume reduction of the gland.
It is challenging to accomplish optimal seed
distribution with acceptable dosimetry in patients
with large defects from previous transurethral
resection of the prostate (TURP). The risk of
incontinence is thought to be higher with patients
who have had a TURP [7,8] although this is now
challenged [9,10]. If the TURP was performed
more than 6 months to a year previously, the
urethral cavity may have healed, but care must
still be taken to minimize the urethral dose.
Patients on regular anticoagulants and
antiplatelet agents should be advised to stop for a
few days preimplantation if it is clinically safe to
do so. The duration will depend on the half-life of
the medication.
Contraindications to LDR brachytherapy as
recommended by ABS and ESTRO/EAU/
EORTC are summarized in Table 2.
2.2
Equipment Required
A transrectal ultrasound (TRUS) probe with

dedicated prostate brachytherapy software.
The ultrasound should ideally be of high
resolution, using frequencies between 5 and
12 Mhz with a biplanar system, to allow
sagittal and transaxial visualization.
Stepping unit support system containing a
cradle to hold the ultrasound probe and allow
three-dimensional movement in the x (leftright), y (anterior-posterior), and z (superiorinferior) axis. The unit can be mounted on the
operating table or placed on the ground.
Table 1 ESTRO/EAU/EORTC recommendations for indications on LDR prostate brachytherapy [3]

PSA (ng/mL)
Gleason score
Stage
IPSS
Prostate volume (g)
Qmax (ml/s)
Residual volume (cm3)
TURP
Recommended (do well)

<10
56
T1c-T2a
08
<40
>15
Optional (fair)
1020
7
T2b-T2c
919
4060
1510
Investigational (poor outcome)

>20
810
T3
>20
>60
<10
>200
+
301
Prostate: Low Dose Rate Brachytherapy

Table 2 Contraindications to LDR brachytherapy
ABS guidelines [11]
Absolute
Limited life expectancy
Unacceptable operative risks
Distant metastases
Absence of rectum, precluding
the use of TRUS
Large TURP defects
Ataxic telangiectasia
Relative
High IPSS >20
History of prior pelvic
radiotherapy
TURP defects
Large median lobes
ESTRO/EAU/EORTC guidelines [3]

Life expectancy less than 5 years
Metastatic disease
Prostate gland >60 cm3 at

implantation
Inflammatory bowel disease
Prostate gland >50 cm3 at implantation
Perineal template that will be fixed onto the stepping system and calibrated to accurately match
the grid displayed on the ultrasound image.
Implantation device and needles. Implantation
needles are usually 18 gauge and 20 cm long.
Locking (stabilization) needles optional.
Foley catheter or aerated gel (lubricating gel
mixed with air in a syringe to produce tiny
bubbles) to visualize the urethra on TRUS.
Fluoroscopy unit. Some units are able to obtain
CT slices to detect areas with cold spots.
2.3
Recent TURP with persisting large defect

Bleeding disorder
has revolutionized prostate brachytherapy [12].

This method allows direct visualization of needles in the prostate guiding precise seed implantation, which in turn enhances dosimetry, and
ultimately translates to improved clinical outcomes. Since then, this technique has been
refined and popularized, becoming the standard
for prostate brachytherapy [13,14]. The last
decade has seen advances in imaging, and the
introduction of sophisticated planning software
technology has further improved the quality of
seed implantation.
Pretreatment Preparation
2.5
1. Patients will require an anesthetic assessment

prior to the procedure. Spinal or general
anesthetic may be used.
2. Laxatives may be given a few days prior to
empty the bowel. An enema is usually given a
few hours before the procedure to empty the
rectum in order to obtain a good visual field
on the TRUS image. If the rectum is still full,
a rectal washout may be necessary before
starting the procedure.
3. An alpha-blocker may be given a few weeks
prior to the procedure if the patient has
existing outflow obstructive symptoms.
2.4
Implantation Technique
The introduction of the transperineal approach

for Iodine-125 seed implantation using transrectal
ultrasound (TRUS) guidance by Holm in 1983
Preimplant Treatment
Planning
Before seed implantation, the patient will undergo

a prostate volume study. TRUS still remains the
standard modality used for the volume study and
has been shown to have close approximation with
prostatectomy prostate volumes [15]. CT imaging
can be used but may overestimate the volume of the
prostate [16]. Many newer brachytherapy software
systems now allow MRI soft tissue registration
with TRUS images, allowing for better soft tissue
visualization while contouring the prostate.
The patient is positioned in the lithotomy
position as shown in Fig. 1. Hyperextension of
the legs can widen the pubic arch for those with a
larger gland. The TRUS probe is then inserted
into the rectum and fixed onto the cradle of the
stepping unit.
The TRUS image of the prostate is positioned
centrally within the displayed template grid on
302
Fig. 1 (a, b) Views of a patient setup in lithotomy position with ultrasound probe inserted into the rectum. The probe
has been fixed onto the cradle (full arrow) of the stepping unit. The dashed arrow points to the template holder
Fig. 2 (a) Good TRUS image of the prostate; (b) Rotated image
the ultrasound image at its largest transverse

slice, usually at the mid-gland. Special attention
must be taken to ensure that the TRUS is inserted
straight and with little pressure around the probe
so that the prostate image is not distorted, angled,
or rotated around the probe. A small amount of
saline can be injected into the condom over the
rectal probe for improved image quality and
assistance in positioning the posterior capsule of
the prostate. The posterior row of the grid (column D, row 1) should be 0.10.2 cm above the
posterior prostate capsule to keep the rectal dose
below prescription point (Fig. 2).
The urethra should be located in the middle of
the grid (column D). A Foley catheter or aerated
gel is inserted into the urethra to assist urethral
visualization. Insertion of aerated gel (Fig. 3) is
preferred as the catheter may pull the urethra

anteriorly, compromising the dosimetric outcome
once the catheter is removed. The catheter may
also distort the prostate leading to inaccurate
target volume delineation [17].
Once the clinician is satisfied with the quality
and reproducibility of the TRUS setup and image,
serial transverse images are taken from the base to
the apex as shown in Fig. 4. This should be in no
more than 0.5 cm increments; 0.1 cm spacing will
improve the 3D reconstruction and also enable
more precise definition of base and apex. A sagittal image that displays both the base and apex of
the prostate is also obtained to measure the length
of the gland. After the images are obtained, data
are transferred into the planning computer treatment planning system (TPS). Target volumes and
303
Fig. 3 (a, b) Sagittal and transverse view of the prostate

on TRUS with aerated gel in the urethra. Inserting a catheter can alter the normal curvature of the urethra, affecting
actual dosimetry received by the prostate when the cathe-
ter has been removed. Bottom row: Same images with target volumes and organs at risk contoured. Red prostate,
light blue prostate with margin, dark blue rectum, green
urethra
Fig. 4 (ai) TRUS 0.5 cm interval slices obtained at volume study with target volume of the prostate outlined from
base (top left) to apex (bottom)
304
organ at risk volumes are outlined, followed by

the generation of a treatment plan.
Table 3 Dose parameter preplan recommendations by

ESTRO/EAU/EORTC for LDR brachytherapy [18]
GTV
CTV
2.6
Volume Denition and Dose

Parameters
ESTRO/EAU/EORTC volume definitions are as

follows in the preimplant setting [18]:
Tumor volume definition
GTV (gross tumor volume) is contoured on
the preimplantation TRUS image in correlation with MRI imaging when available.
CTV (clinical target volume) is the whole
prostate gland with a margin expanded
with constrains to the anterior rectal wall
(posterior) and bladder neck (cranial):
T1-T2 CTV = visible prostate contour +
0.3 cm margin
T3 CTV = visible prostate contour +
visible extracapsular extension + 0.3 cm
margin
PTV = CTV
Organs at risk (OAR)
Prostatic urethra Defined by aerated gel or a
small gauge catheter when the surface of the
catheter is used to define the urethral surface.
Rectum Visualization of the anterior rectal wall is good on TRUS. The outer and
inner walls should be outlined.
The preplan dose parameters recommended by
ESTRO/EAU/EORTC are summarized in Table 3.
The ABS guidelines limit the preplan dose parameters for the dose applied to <1 cc of the rectum to
100 % of the prescription dose (RV 100 < 1 cc)
[11]. It is important to aim for a higher preplan
D90 as post implant D90 dosimetry is generally
lower and targets are often not achieved [19].
2.7
Treatment Planning
Techniques
2.7.1 Preplanning
The original approach was to perform a two-step
procedure where the volume study is performed
during a separate procedure a few days or weeks
OAR: rectum
OAR: prostatic
urethra
GTV >150 %
V100 95 %
D90 > 100 %
V150 50 %
Primary: D2cc < 145 Gy
Secondary: D0.1 cc (Dmax)
< 200 Gy
Primary: D10 < 150 %
Secondary: D30 < 130 %
before the implantation. The volume study is

undertaken and a dose plan that can be reproduced during the implantation procedure is then
created. There are a few benefits to this method.
It allows planning of optimal source placement to
maximize coverage of the target volume. The
exact number of seeds required can be predicted
accurately and ordered, or alternatively preloaded
needles can be ordered. Pubic arch interference
can be assessed and patients with a large gland
requiring cytoreduction can be identified.
However, several limitations are associated
with this preplanning approach [20].
Reproducibility of TRUS images at implantation
to match those obtained at preplanning is
extremely challenging due to variation of patient
repositioning and TRUS probe setup. The prostate shape or volume may change in between preplanning and implantation with pelvic floor
muscle relaxation from anesthesia or the use of
antiandrogens. Therefore an implant based on the
preplan technique may lead to inaccuracies and
poor dose distributions.
2.7.2 Intraoperative Planning

Most units have now moved toward the intraoperative planning technique which is a one-step
approach where the volume study, treatment
planning, and seed implantation are all performed
as one procedure to overcome positional uncertainties. This also provides the opportunity to
improve the quality of implants by modifying
and replanning during the procedure. There are
several approaches to intraoperative planning as
defined by the American Brachytherapy Society
(ABS): intraoperative preplanning, interactive
planning, and dynamic dose calculation [21].
Intraoperative Preplanning
This technique brings the planning system into
the operating room (OR). As there is no preplan
done beforehand, the number of seeds required is
determined from a nomogram or table based on
the prostate volume deduced from a CT scan or
ultrasound. The TRUS images obtained in the
OR are transferred real time into the TPS for the
treatment plan creation, followed immediately by
the implant procedure.
Although operating time is lengthened,
dosimetry is generally better with intraoperative
preplanning when compared to conventional
preplanning. This technique obviates patient
repositioning issues but does not account for
intraoperative variations in prostate geometry or
deviations of the implant needle insertion from
the plan [22].
Interactive Planning
Interactive planning allows intraoperative
optimization of the treatment plan using real time
dose calculation updates from image-based
needle position feedback during the implant
procedure [21]. The intraoperative preplan
method described earlier is used to generate the
initial treatment plan. Once the implant needles
are inserted into the prostate, the positions are
registered by the TPS. The dose is then
recalculated based on the imaged needle
positions, giving a more accurate dosimetric
representation. Seed loading can be modified,
individual needle positions can be adjusted, and
additional needles can be added to optimize the
plan if the dosimetry is found to be suboptimal
before the sources are deposited. It has been
shown that this method produces better dosimetry
for the CTV [23] and has been associated with
improved biochemical control [24,25].
Advances in technology with improved ultrasound resolution, automated stepping, and tracking systems allow quicker and more accurate
plan modifications [26]. It has also been proposed
that the learning curve for new brachytherapists
may be reduced as corrections during the
procedure can be made. This technique also
accommodates intraoperative changes within the
prostate and deviations in the inserted implant
needle position from the intended position on the
305
preplan. However, as it uses information based

on needle position, it does not account for actual
implanted seed location, loose seed migration, or
stranded seed retraction from the prostate apex
after implantation or the effects of intraoperative
prostate edema on final seed placement.
Dynamic Dose Calculation
Dynamic dose calculation refers to optimization
of the treatment plan in a 3D setting based on
continuous deposited seed position feedback. It is
important to note that information is gathered
from each individual seed implanted position
rather than the needle position as in the interactive
planning method. This technique provides the
most accurate representation of the dose
delivered.
However, it is not yet commercially available
as the ability to track individual seeds reliably for
dosimetric calculation is limited with current
TRUS technology. Several methods are under
development including TRUS fusion with
fluoroscopy [27,28] and intraoperative C-arm
cone beam CT [29].
Robotic systems with promising results are
also in development to assist the improvement of
seed placement accuracy [30].
2.8
Dosimetry Planning
Techniques
There are various seed loading planning

techniques used as shown in Fig. 5. The Seattle
group initially utilized a uniform loading
approach with a high number of low-activity
seeds evenly distributed at a 1 cm distance
throughout the prostate [31] which maintains
dose homogeneity despite small variations in
seed placement. This however causes underdosing
of the periphery due to the scalloping-in effect
and significant overdosing of the central (urethral)
portion of the gland which can approach almost
300 % of the prescribed dose, resulting in
increased urinary morbidity [32].
The peripheral loading approach has evolved
where a lower number of high-activity seeds were
implanted only around the periphery of the gland
[33]. This technique spares the urethra but at the
306
Fig. 5 Dosimetry using the uniform loading approach (left), peripheral loading approach (middle), and modified
approach (right)
expense of underdosing the prostate centrally and

resulting in undesirable high dose gradients close
to the rectum. Slight seed misplacement or migration may also affect dosimetry significantly.
To overcome disadvantages in both techniques, most centers now use a merged approach,
modified uniform [34] or modified peripheral
loading [35], depending on the starting reference.
Both utilize the concept of increasing the number
of seeds at the periphery, especially at the base
and apical region of the gland, while reducing
central seed density adjacent to the urethra. More
sophisticated derivations of this approach may
also use seeds of different activity with higher
activity seeds around the periphery.
2.9
Implant Procedure
The patient is repositioned in a similar lithotomy

position as the volume study if the preplan method
is used. The ultrasound setup will then be reproduced as close as possible to that during the volume study. The one-step procedure simply flows
continuously from the volume study acquisition

to dose plan generation to implantation.
The scrotum is lifted up and taped or suture
retracted away from the perineum and the perineal area is disinfected. The perineal template is
mounted onto the stepping unit and is checked
that it correlates with the template grid displayed
on the ultrasound image. Most templates are
made with 0.5 cm spacing.
Locking or fixation needles can be used to fix
the prostate but are not implemented universally.
The prostate is a soft structure that can move and
change in shape when needles are inserted. The
preplan will contain a needle loading report that
indicates for each needle:
The x and y coordinate
The number of seeds including special
loadings
Retraction of needle tip from base plane (z
coordinate)
Seeds may be ordered loose or stranded.
Loose seeds are associated with a higher trend of
migration than stranded seeds [36,37]. Seed

migration is rare and can occur up to 1-year postprocedure. Seeds may pass through the urine or
may migrate to the lung or pelvic lymph nodes.
Although there are concerns that stranded seeds
are associated with intraprostatic seed movement
in the weeks post implantation due to prostate
edema, there appears to be little effect on the post
implant dosimetry [38]. Increased experience
and avoidance of seed placement in periprostatic
vessels are associated with a reduction in seed
migration [39].
Most needles will implant a fixed number of
25 seeds; there may also be special loadings
with no seeds in the middle portion of the track.
These are normally used adjacent to the urethra
to keep the urethral dose low (Fig. 6).
The implantation process is shown in Figs. 7
and 8. It is usually begun from the anterior row
first to minimize TRUS interference. The needle
is advanced into the prostate guided by the
TRUS transverse imaging set at the corresponding retraction plane slice. The needle can be
rotated to check that tip of the bevel flashes up
and down to ensure that it is at the correct depth.
The probe is then rotated within the cradle so
that the sagittal crystal is focused on the needle
to verify its depth. The seeds are then advanced
Fig. 6 Tray containing

preloaded needles
ordered based on the
needle implant report.
The distance between
the stylet tip and needle
hub after the seeds are
advanced is used as a
reference to correlate
with the number of
seeds contained within
the needle
307
into the intended position along the needle using

the stylet, using the final distance from the stylet
tip to the needle hub as a reference to the number of seeds in the needle. Special loaded needles will have a longer distance than the total
number of seeds in the needle as spacers are
used in place of the absent seeds. If the stylet is
advanced too deeply or too quickly, the seeds
may be pushed beyond the intended position.
Once in position, seeds are deposited carefully
by holding the stylet stationary and carefully
withdrawing the needle over the stylet. If the
needle is pulled out too swiftly, the seeds may
slip inferiorly due to the suction effect from
withdrawal [40].
There are two main methods of seed placement, the preloaded technique and the afterloading technique. With the preloaded technique,
seeds are placed into the needle beforehand and
deposited immediately into the prostate once the
needle is inserted. The needles can be manually
preloaded or ordered preloaded based on the
needle loading report. With the afterloading
technique, the needles are positioned in the
prostate first, either all at once or by row. The
seeds are then inserted into the needle while it is
in the prostate. This generates the desired alignment of a train of seeds and spacers, and the
308
Fig. 7 Insertion of implant needle and deposition of

seeds. (a) Stabilization needles inserted transperineally
via the template into the prostate. (b) Preloaded implant
needle inserted into the prostate until the tip is visualized
on the reference plane on TRUS as shown in (a). (c) Stylet
is slowly pushed in to advance seeds along the needle to
the intended position. It is important to stabilize the needle using the nondominant hand (left in this picture) to
minimize the possibility of pushing the needle further in.
(d) Needle is withdrawn over the stylet with the stylet held
stationary to deposit the seeds. (e) Both needle and stylet
being removed
train is pushed into the prostate remotely. The

needle is retracted until it is just outside of the
prostate and is then further retracted by the
operator (Fig. 9).
seeds can be calculated on the fluoroscopic image

to ensure all seeds are accounted for before leaving the operating room. A Geiger-Muller counter
or scintillation detector is used to survey the
operating area for any misplaced seeds.
A cystoscopy may be done if there is concern
about loose seeds in the bladder; however, this
rarely happens and if so, free seeds will normally
pass naturally (Fig. 10).
2.9.1 Post Procedure

A fluoroscopic image is taken and an ultrasound
scan from base to apex is reviewed to ensure
good coverage of the prostate. The number of
309
e
Fig. 8 (ae) TRUS views showing implant needle insertion
and deposition of seeds. (a) Tip of the bevel at reference
plane. Two horizontal lines can be seen. When the bevel is
rotated, the horizontal line will flash. (b) Probe is tilted so
that the needle image is at midline to visualize the needle in

sagittal mode. (c) Needle in sagittal view. (d) Needle being
withdrawn over a strand of seeds. (e) Strand of seeds deposited and needle is slowly removed
Dosimetry
3.1
Choice of Radioisotopes
and Prescription Doses
is equivalent to 144 Gy using TG-43 calculations

[41]. Cesium-131 is a fairly new radioisotope
introduced recently in 2004, and a prescription
dose of 115 Gy is recommended for monotherapy
[42]. The ABS guidelines in 2012 have not made
any recommendations on the use of Cesium-131
as follow-up data are still immature.
Permanent seed implants may use Iodine-125,

Palladium-103, or Cesium-131. Iodine-125 is the
usual isotope used in Europe. The properties and
published recommendations for dose prescriptions are summarized in Table 4. The dose is prescribed to a minimum peripheral dose, which is
the 100 % isodose.
Iodine-125 dose prescriptions in early literature
(pre-TG-43 era) may be reported as 160 Gy, which
3.2
Post Implant Dosimetry
It is good clinical practice for all implants to

undergo evaluation to ensure good quality
control of the implant. There is evidence
310
Fig. 9 Periprostatic
vessels (arrows). Care
should be taken not to
insert seeds into this
area
Fig. 10 (a) Fluoroscopy at D0 post implant. (b) Pelvic radiograph of same patient at D30 showing a strand of seeds
migrating inferiorly. (c) Pelvic radiograph of another patient with migration of seeds into the bladder
Table 4 Radionuclide properties and prescription doses recommendations for LDR prostate brachytherapy
Seed strength
Radionuclide
Iodine-125
Palladium-103
Caesium-131
Halflife
(days)
59.4
17
9.7
Initial dose
rate
(cGy.h1)
7
21
30
Average
energy
(keV)
28.4
20.7
30.4
mCi
0.30.6
1.12.2
2.53.9
U
0.40.8
1.41.8
1.62.5
Prescription dose (Gy) using AAPM TG-43

formalism
Combination
Monotherapy
Monotherapy with EBRT
(ESTRO)
(ABS) [11]
(ABS) [11]
[18]
145
140160
108110
125
110125
90100
N/A
N/A
N/A
U is the unit for air kerma strength, 1U = 1 cGy cm2 h1, EBRT external beam radiation therapy, Recommended EBRT
dose = 41.450.4 Gy (1.8 Gy2 Gy/day)
suggesting that the probability of achieving

biochemical control has a strong correlation
with the quality of an implant, represented by
the D90, the minimum dose delivered to 90 %

of the target volume on post implant dosimetric
analysis [43,44].
311
Table 5 Published recommendations from ABS [11,51] and ESTRO/EAU/EORTC [3,18] on post implant dosimetry
reporting in LDR prostate brachytherapy
ESTRO/EAU/EORTC
Primary parameters
Mandatory
D90
V100
V150
Prostate CTV
ABS
D100, D90, D80
V200, V150, V100, V90, V80
OAR: rectum
RV100
D2cc
OAR: urethra
UV150
UV5
UV30
Total volume of prostate
Number of days between
implantation and post implant
imaging study
D10
Other reporting
recommendations
Secondary parameters
May be reported
V200
D100
Natural dose rate
Homogeneity
index
Conformal index
D0.1cc
V100
D0.1cc
D30
D5
Volume implanted
Number of seeds
Number of needles used
Total activity implanted
Prescribed dose
ESTRO recommends that volume (V) parameters should always be expressed in absolute values (cc)
OAR organs at risk, D90 dose covering 90 % of the prostate volume, V100 volume that has received 100 % of the prescribed dose, UV urethral volume, RV rectal volume
The timing of post implant imaging will produce different results in post implant dosimetry
due to the varying degrees of trauma-related
prostatic edema. Imaging performed immediately post implant (day 0) will underestimate the
dosimetric parameters by about 10 % as the mean
prostatic volume is increased [45]. ABS recommends CT-based post implant dosimetry to be
performed within 60 days of the implant with the
optimum timing depending on the radionuclide
used: 16 4 days for palladium-103 and 30 7
days for iodine-125 [11].
Interobserver and intraobserver variability in
CT-based post implant contouring of the prostate
due to poor soft tissue visualization contributes to
variability in prostate dosimetry [46,47]. CT
images may also be degraded due to scatter from
the metallic seeds. Despite the fact that MRI
improves soft tissue definition, MRI-based post
implant contouring of the prostate was also found
to have large interobserver variability caused by
the lack of uniformity in the interpretation of the
prostate CTV [48], despite contouring recommendations from ESTRO mentioned below.
CT imaging still remains the best means of
seed localization. On MRI, seeds are seen as sig-
nal voids and are more difficult to individualize.

Seeds may appear on more than one CT slice;
hence use of a seed sorting software algorithm is
recommended. Optimal post implant imaging
includes performing both CT and MRI with
image fusion to improve the reproducibility of
post implant dosimetry [49,50]. However, there
are uncertainties on image fusion and these may
account for variability up to 16 % for CT and T2
MRI fusion [48].
The ABS and ESTRO have both recommended a set of dosevolume parameters to be
reported for post implant evaluation as shown in
Table 5.
ESTRO has published recommendations to
promote uniformity in contouring the prostate
and organs at risk for post implant dosimetry
evaluation [18]:
There are two prostate CTV definitions and
both should be reported:
CTV-P = CTV for prostate, i.e., the prostatic gland capsule on post implant radiological imaging is contoured.
CTV-PM = CTV for prostate plus 0.3 cm
three-dimensional uniform margin.
312
Prostatic urethra Definition is poor both on

CT and MRI. It is only accurate when a urinary catheter or aerated gel is inserted during
post implant imaging, which may not always
be practical. Correlation or fusion of CT or
MRI images with TRUS images may be the
optimal noninvasive technique for urethral
localization. It is recommended that institutional policy should be described if urethral
parameters are published.
Rectum If using CT only, outer rectal wall
can be clearly defined. If using MRI, outer and
inner walls can be defined. There is controversy as to whether there is a need to outline
the inner wall for post implant dosimetry. For
dosevolume parameters of D2cc and below,
there is no impact, but for larger dosevolume
criteria, errors may be introduced from just
the outer wall contours [52].
The penile bulb and neurovascular bundles
can only be defined accurately on MRI, but dose
parameters to these structures are still under
investigation.
Results
Outcome is generally measured as biochemical

relapse-free survival (bRFS) as the natural history of localized prostate cancer is generally
slow. Overall survival is not a common end point
as most men with low- and intermediate-risk
prostate cancer die of other age-related comor-
bidities rather than their prostate cancer [53].

Several definitions of biochemical failure have
been used, which may contribute to differences in
reported outcomes. At present, the Phoenix definition, a PSA rise of 2 ng/ml above posttreatment nadir, introduced in 2006, is the widely
accepted criterion used [54].
There has been extensive literature published
on the results of primary LDR prostate brachytherapy monotherapy to date, and as a result, it is
a very well-established treatment option for lowrisk disease. For LDR brachytherapy alone, the
10-year bPFS is approximately 80 % for low risk,
6070 % for intermediate risk, and 3060 % for
high-risk disease.
Large studies with more than 900 patients and
long-term results on LDR seed monotherapy are
summarized in Table 6. The largest cohort is a
multi-institutional study by Zelefsky describing
outcomes of 2693 patients with T1-T2 disease
treated with permanent brachytherapy only without androgen deprivation. 1831 were treated with
I-125 implants and 893 were treated with Pd-103
implants. No difference in outcomes was found
between the different isotopes. The 8-year PSA
relapse-free survival using the Phoenix definition
of relapse was 74, 61, and 39 % for the low-risk,
intermediate-risk, and high-risk group stratified
using the National Comprehensive Cancer
Network (NCCN) risk criteria [55].
LDR seed brachytherapy can be used in conjunction with external beam radiotherapy
(EBRT) in the intermediate- and high-risk settings to dose escalate. Long-term outcomes are
Table 6 Summary of representative results on LDR seed brachytherapy monotherapy from selected large patient
cohorts
Number of
patients
2693
Median
follow-up
(years)
Total
follow-up
(years)
5.3
Henry et al.
[56]
1298
4.9
10
Hinnen et al.
[57]
921
5.75
10
Author
Zelefsky et al.
[55]
bNED (%)
Recurrence
definition
ASTRO
Phoenix
ASTRO
Phoenix
Phoenix
Low risk
82
74
86
72
88
Int risk
70
61
77
73
61
High Risk
48
39
61
58
30
bNED biochemical no evidence of disease, ASTRO definition 3 successive rises in PSA after posttreatment nadir
achieved [58], Phoenix definition absolute posttreatment nadir plus 2 ng/mL [54]
313
shown in Table 7. A recent randomized controlled trial from Canada has been reported in
abstract demonstrating the superiority of this
approach over external beam radiotherapy to
74 Gy alone [62].
Outcomes for prostate LDR brachytherapy are
comparable to other radical treatment modalities,
and one large comparative analysis has reported
superior bRFS outcomes for LDR brachytherapy
compared to radical prostatectomy or EBRT in the
low-risk and intermediate-risk setting. Patients in
the high-risk group performed better with combined
treatment using brachytherapy and EBRT [63].
There is a doseresponse relationship between
the post implant quality, represented by the post
implant D90 and clinical efficacy. Stock first introduced this concept in 1998 when he demonstrated
improved bRFS rates with higher D90 values. In
this series, the bRFS at 4 years was 92 % for
patients with D90 >140 Gy versus 68 % for those
with D90 <140 Gy [44]. Zelefsky demonstrated
significantly higher 8-year bRFS rates when the
D90 was >130 Gy at 93 % versus 76 % when the
D90 was <130 Gy [55]. Several other series have
also confirmed this association [43,64].
Approximately 30 % of patients experience
the PSA bounce phenomenon, where there is
a temporary rise in PSA after an initial fall
[65,66]. This is usually seen 1224 months
posttreatment with average rises of <2 ng/ml.
The bounce is benign and should not be a trigger
for salvage therapy. If a prostate biopsy is undertaken before 30 months following an implant
due to a rising PSA, the biopsy result may not

be interpretable [67].
The time taken for the PSA to achieve its nadir
value is slow and can take up to 6 years [68]. The
nadir value has been found to be a prognostic indicator of long-term biochemical outcome. Zelefsky
has shown that the 8-year bRFS outcome using the
Phoenix definition was 88 %, 69 %, 57 %, and
41 %, respectively, for patients with a 3-year PSA
nadir value of 00.49, 0.50.99, 1.01.99, and >2.
For patients who maintained bRFS at 8 years, the
median PSA nadir level was 0.1 ng/ml [55].
4.1
Salvage Brachytherapy
LDR brachytherapy has also been used for

salvage after local recurrence following previous
radiation therapy. It is feasible but few mature
results
are
available
to
make
firm
recommendations. It should be performed at an
experienced center in prostate brachytherapy,
undertaking prospective data collection.
4.2
Post Implantation Care
Perineal bruising after implant is common and

perineal ice packs may be advised.
Post implant prophylactic antibiotics are
recommended for one week.
Obstructive and irritative urinary symptoms
are very common and can last for a few
Table 7 Summary of representative results on LDR seed brachytherapy combined with EBRT
Author
Sylvester et al.
[8]
Dattoli et al.
[59]
Merrick et al.
[60]
Critz and
Levinson [61]
Number of
patients
223
Median
follow-up
(years)
9.43
Total
follow-up
(years)
15
321
10.5
16
284
7.8
12
1469
10
bNED (%)
Recurrence
definition
Modified
ASTRO
Phoenix
PSA > 0.4
above nadir
Phoenix
PSA > 0.2
Modified ASTRO definition 2 successive rises in PSA at time of last follow-up
Low risk
85.8
Int risk
80.3
High risk
67.8
89
74
89
93
80
88.4
61
314
months. Prophylactic postoperative alphablockers can improve urinary morbidity [69].

Prophylactic anti-inflammatory drugs can also
be prescribed to improve dysuria.
Urine needs to be passed via a sieve while in
hospital extended in some recommendations
to 3 days after the implant to catch any loose
seeds passing via the urethra. If a seed is
found, then a spoon or forceps is used to pick
it and dispose of in a sanitary system. If it is in
the lavatory, it can be flushed away. At some
institutions, this is not a requirement.
Sexual intercourse may be resumed, but some
practitioners recommend condom use for the
first few ejaculations, although the likelihood
of ejaculation of a seed is very low.
The range of radiation outside the patient is
very low and there is little radiation risk to
others [70]. It is however still recommended
that children and pregnant women should
avoid close contact (less than one meter) for
one half-life of the radionuclide.
The patient should be given written information about the implanted sources, strength of
radiation, date of implantation, and contact
numbers. A wallet card should also be given
to the patient.
Cremation may cause contamination and
release radioactive material into the atmosphere and is not recommended for 2 years
post implantation.
Further information regarding radiation safety

for permanent prostate implants can be found in
more detail in the ICRP 98 document [71].
Complications
The main complications from permanent seed

implants are from urinary, bowel, and sexual
dysfunction.
The majority of patients who develop complications develop urethritis with increased urinary
frequency and obstructive and irritative symptoms which start a few days post implant and may
persist up to 69 months after. The symptoms for
90 % of men resolve at 1 year once most of the
total dose is delivered [72]. For Iodine-125, 75 %

is delivered by 4 months and 97 % by 8 months.
Acute urinary retention happens in 510 % of
patients. It should be managed conservatively in
the first instance with alpha-blockers and
intermittent self-catheterization or continuous
drainage with a Foley catheter. The probability of
developing acute retention correlates with the
pretreatment IPSS score and prostate size and is
related to prior use of alpha-blocking drugs,
tobacco use, and age [73]. Retention normally
resolves within the first year and should be treated
conservatively. If a TURP is performed in the
first year post-treatment, there is a higher risk of
urinary incontinence [74].
Chronic urinary morbidity can occur
secondary to excessive irradiation of the bladder
neck or prostatic urethra. RTOG grade 3 toxicity
is reported in 13 % of treated patients [75] and
urethral stricture rates are up to 12 % [76]. Longterm incontinence is strongly associated with
previous TURP surgery, with up to 20 %
incontinence rates in the group who underwent
TURP versus 1 % without TURP in one series
[8]. Newer evidence is emerging which may
support post TURP implantation in selected
circumstances.
Chronic radiation proctitis is rare, seen in less
than 5 % of patients. It may present 6 months
post implant with rectal bleeding, rectal urgency,
rectal incontinence, and pain. Rates of rectal
fistulas are low, around 0.6 % [77]. The distance
between posterior seeds implanted and the
anterior rectal wall is correlated with rectal
toxicity, and improved technology in implant
positioning accuracy has improved rates of
toxicity.
Erectile dysfunction rates are generally lower
with permanent seed implants compared to other
treatment modalities. The rate of erectile
dysfunction has a significant correlation with
preimplant erectile status. Thirty percent of men
potent prior to the implant will develop impotence
but 60 % will respond to phosphodiesterase
inhibitors [78].
LDR brachytherapy does not seem to be
related with an increased risk of radiationinduced secondary malignancy compared to the
general population. A systematic review has

supported this conclusion, and it is felt that this
could be attributed to the high sterilizing doses
received by small regions only around the treated
area [79].
315
5.
6.
Summary
7.
Low dose rate brachytherapy using the

transperineal transrectal ultrasound-guided
approach is now well established as an effective
treatment for both low- and intermediate-risk
prostate cancer. The technique has evolved from
the original two-step process to a single-step
procedure in which a preimplant volume study is
undertaken, plan produced, and seeds inserted
during a single event. This also enables interactive
planning with tracking and correction of seed
placement as the implant is built up. Seeds may
be used singly using a Mick applicator or in a
stranded form with no consistent advantage seen
for either approach. Post plan dosimetry is
important for quality assurance and governance;
a D90 of at least 130 Gy using I-125 should be
the target. Overall biochemical relapse-free
survival rates of around 90 % in low risk and
80 % in intermediate-risk patients are to be
expected. The main toxicities are urinary with
acute irritative symptoms in the first year and
later urethral stricture as the most common
events. Rectal changes are less frequent and
erectile dysfunction will occur in 3040 % of
men potent prior to the implant.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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the clinical data and impact of treatment technique.
Prostate: High-Dose Rate

Brachytherapy in the Treatment
of Clinically Organ-Conned
Prostate Cancer
Nikolaos Tselis, Dimos Baltas,
and Nikolaos Zamboglou
Abstract
High-dose rate brachytherapy for prostate cancer has enjoyed rapid

acceptance and is one of the most active areas of clinical research in the
field. We present this chapter as a comprehensive technical analysis of
rationale, methods, and outcomes including a substantive data review.
Introduction
In patients with clinically organ-confined prostate

cancer, radical prostatectomy [1, 2], external beam
radiotherapy (EBRT) [35], permanent low-dose
rate (LDR) brachytherapy (BRT) [68] and temporary high-dose rate (HDR) BRT [918] are
established treatment options. In the absence of
randomized clinical trials, however, survival and
biochemical control (BC) data are difficult to
assess, and the optimal therapeutic strategy
remains controversial. Against this background,
quality of life issues have gained increasing importance in the choice of interventional treatment with
BRT gaining momentum due to its potential
N. Tselis, MD, PhD (*) N. Zamboglou, MD, PhD
Department of Radiation Oncology and
Interdisciplinary Oncology, Sana Klinikum,
Offenbach, Germany
e-mail: [email protected];
[email protected]
D. Baltas, PhD
Department of Medical Physics and Engineering,
advantages of convenience, high effectiveness,

and relatively low morbidity. By now, a large body
of literature corroborates the efficacy of both permanent and temporary BRT in the treatment of
localized prostate cancer. Especially research on
HDR BRT is accelerating, reporting technological
improvements in ultrasound-based real-time
image guidance with one-step intraoperative treatment planning which ensures high standards of
implant quality [19]. In fact, the superior dosimetry of HDR temporary afterloading BRT is
reflected in the growing number of recent publications reporting excellent clinical results [2022],
thus supporting HDR BRT as an innovative alternative to permanent LDR BRT [23].
Background
2.1
Rationale for HDR

Brachytherapy
Recent clinical research suggests that radiation

dose escalation for localized prostate cancer not

DOI 10.1007/978-3-319-26791-3_19
319
N. Tselis et al.
320
only improves biochemical disease control [4, 5,

24] but also results in improved local control
(LC) and metastasis-free survival (MFS) [5, 25
29]. In this context, patients without regionally
advanced or metastatic disease may benefit most
from dose-escalated radical radiotherapy (RT),
and it is reasonable to assume that further
improvements in the therapeutic ratio can be
generated by escalating the treatment dose while
ameliorating dose conformity. High-dose rate
BRT meets this objective optimally by exploiting
the radiobiological advantage of large fraction
sizes [3032] while ensuring intraoperative realtime treatment planning and delivery [33] with
prospective three-dimensional (3D) dosimetry
[34]. High-dose rate treatment planning provides
anatomy-based
multiparametric
dose
optimization through modulation of catheter
geometry, radiation source positions, and source
dwell times [35, 36]. The versatility of intratarget
dose modulation inherent to HDR BRT can be
controlled and directed to deliver higher doses to
gross disease or to selectively reduce the dose to
organs at risk (OARs) [20]. In comparison to
permanent LDR BRT, HDR dosimetry is high
density because there are approximately twice
as many HDR dwell positions as seeds in the
typical LDR implant. The prospective nature of
HDR dosimetry ensures excellent target coverage
and normal tissue sparing without dosimetric
changes caused by source migration and tissue
deformity which are common problems
associated with permanent LDR seed implants
[3739]. Furthermore, variations in internal anatomy secondary to organ motion, which frequently occur during treatment delivery times in
EBRT [4042], and setup inaccuracies are not an
issue with HDR because they can be corrected
with interactive online dosimetry during the
implantation procedure or modified during realtime anatomy-based treatment planning before
dose delivery [20]. Since there is no need to add
treatment volume beyond the intended target to
account for patient motion or variations in beam
delivery, the precise 3D dosimetry of HDR allows
the technique to be used in combination with
EBRT. This is of particular relevance when it is
deemed clinically necessary to extend the treat-
ment volume to include areas of possible extraprostatic extension or the regional lymphatic
drainage to a moderate dose while administering
an escalated dose to the prostate.
2.2
Radiobiological
Considerations
Radiobiological research demonstrates that the

probabilities of acute and late radiation reactions
vary between normal tissues and tumors and
between different RT dose fractionation
schedules. The / ratio, a means of expressing
the sensitivity of a particular tissue to altered
fraction size, is used to estimate the impact of a
given schedule on tumor control and toxicity
while enabling comparisons between different
treatment schedules. Tissues and tumors with a
low / ratio have a higher sensitivity to changes
in fraction size than those with a high / ratio
[30, 4345]. Recent radiobiological findings
support a low / ratio, 1.23.0 Gy, for prostate
adenocarcinoma which is lower than the / ratio
of acutely and late-reacting normal tissues [31,
46, 47]. For prostate cancer, this implies that a
hypofractionated dose regimen is favored for
tumor control with a reduction in late sequelae.
Hypofractionated HDR BRT with anatomybased dose optimization is an excellent method
for conformal dose escalation in terms of both
radiation biology and physics [48]. In order to
compare HDR regimes with EBRT treatment
schemes, the linear-quadratic formula as
described by Fowler et al. [43] is usually used:
d
BED = D 1 +
a
( / b )
where BED is the biologically effective dose as a
measure of the biological effect delivered by a
particular RT regime, D is the total treatment
dose, and d is the dose per fraction. In addition
and in accordance with the linear-quadratic
formula, the term equieffective dose, EQDX, has
been introduced and is defined as the total
absorbed dose delivered by the reference
treatment plan (fraction size X) that leads to the
Prostate: High-Dose Rate Brachytherapy in the Treatment of Clinically Organ-Confined Prostate Cancer
same biological effect as the treatment plan that

is conducted with absorbed dose per fraction d
and total absorbed dose D [49]. In this sense,
BED in the above equation is the equieffective
dose EQD0 (X = 0 Gy). To understand by
intuition, the comparison of RT schedules
consisting of different total dose or dose per
fraction is better possible by converting each RT
schedule into an equivalent schedule in 2.0 Gy
fractions which would give the same biological
effect, the equieffective dose EQD2:
EQD2 = D
(d + a / b )
(2 + a / b )
where D is the total treatment dose and d the dose

per fraction of the fractionation scheme under
investigation. Based on those formulae for
calculating equieffective dose, when comparing
HDR BRT with definitive conventional EBRT
(including dose-escalated IMRT), the clinically
delivered dose with HDR BRT regimens is up to
50 % higher compared to conventional EBRT
schemes [11, 14, 22, 5056].
2.3
Patient Selection for HDR

Brachytherapy
Based on the assumption that failure to eradicate

organ-confined prostate cancer may lead to the
development of metastatic disease, the main
indication for HDR treatment is histologically
proven localized disease in patients considered
suitable for radical treatment [57, 58]. In this
context, the National Comprehensive Cancer
Network (NCCN) [59] defined that low- and
intermediate-risk cases are more likely to have
disease confined to the prostate region and
therefore are logically the best candidates for
local treatment. Mature results exist for the
application of HDR BRT as a boost modality in
combination with EBRT for patients with
intermediate- and high-risk disease according to
the risk stratification schemes as described by
DAmico et al. [2], Zelefsky et al. [60] or the
National Comprehensive Cancer Network
(NCCN) [61]. In addition, a growing body of
321
literature corroborates its safe use as monotherapy

with excellent oncological results predominantly
for low- and intermediate-risk disease. However,
some authors have elected to use HDR
monotherapy in high-risk patients based on the
idea that it provides a treatment margin greater
than radical prostatectomy and the dose to the
bladder and rectum remain significantly lower
than when treating with definitive dose-escalated
EBRT. In the clinical setting of regional
lymphadenopathy with or without distant disease
spread, HDR BRT may be implemented
combined with EBRT in individualized treatment
schemes in order to avoid increased toxicity
where RT is employed with the goal of increased
local disease control.
Pretreatment investigations for HDR BRT
should follow the European Association of
Urology [62], European Society for Radiotherapy
and Oncology (ESTRO) [58], and American
Brachytherapy Society (ABS) [57] guidelines.
All patients considered for interstitial (IRT)
irradiation should have histological confirmation
of malignancy, and staging tests for evaluation of
disease burden should include digital rectal
examination, transrectal ultrasound (TRUS), and,
if indicated, computed tomography (CT) and/or
magnetic resonance imaging (MRI) and bone
scintigraphy. In equivocal cases of regional
lymphadenopathy,
laparoscopic
pelvic
lymphadenectomy [63] or positron emission
tomography [64, 65] may be considered.
Although functional outcome after IRT BRT
is predicted by the baseline urinary function
[66], neither larger gland size nor previous
transurethral resection of the prostate (TURP)
are absolute contraindications for treatment.
Transperineal TRUS-guided implantation
enables the complete and safe coverage of
prostate volumes appreciably greater than
50 cm3 provided the patient has a sufficiently
broad pelvic inlet and freedom from lower urinary tract symptoms (LUTS) requiring treatment [34, 57, 6770]. However, HDR appears
to be less likely to cause prolonged exacerbation of urination symptoms than LDR or EBRT
because even patients with International
Prostate Symptom Score (IPSS) of 20 or higher
N. Tselis et al.
322
tend to have a relatively rapid return to pretreatment baseline urinary function [70]. In
addition, temporary implantation with HDR
irradiation is safely feasible at >3 months after
TURP given a sufficient amount of residual
gland volume for image-based 3D treatment
planning [20, 7174]. Nonetheless, HDR BRT
may be technically feasible even after extensive TURP in selected cases because it uses a
scaffolding of catheters to hold the radiation
source, and the dose to OARs be anatomybased optimised given adequate imaging for
treatment planning [74].
Selection criteria for HDR BRT as monotherapy or combined with EBRT are shown in
Table 1. Unlike for permanent LDR implants,
temporary HDR BRT afterloading catheters can
be implanted next to extracapsular lesions or the
seminal vesicles or even into the bladder pouch.
Therefore, the indication for HDR BRT is by
various groups extended to even T4 tumors as
part of curative treatment schemes [14, 56, 75,
76]. Previous pelvic EBRT, inflammatory bowel
disease, and prior pelvic surgery are not absolute
contraindications to prostate BRT, but the anatomy-based dosimetry must include carefully
defined normal tissue dose constraints and there
must be a very cautious evaluation of the potential risks and benefits [20].
Table 1 Patient selection criteria for HDR BRT in the

treatment of prostate cancer
Inclusion criteria
Stages T1T3ba
Any Gleason score
Any PSA level
Exclusion criteria
TURP within 3 months
IPSS > 20
Pubic arch interference
Lithotomy position not possibleb
Anesthesia not possible
Rectal fistula
a
T4 tumors included with curative intent in the protocols
of selected centers [14, 56, 75, 76]
b
Relevant for TRUS-guided techniques, not relevant for
MRI-guided implantation [77, 78]
Treatment Procedure
3.1
Implantation Techniques
Interstitial catheter implantation is usually

performed under spinal or general anesthesia
with various catheter placement patterns being
described. Extensive experience exists for the
technique of TRUS-guided implantation [911,
17, 48, 79]; however, MRI-based implantation
techniques have also been reported in the
literature [77, 78].
In case of the TRUS-based technique, implantation is performed transperineally in high lithotomy position using a continuous probe movement
technique and a template to aid catheter placement. The clinical workflow includes the creation
of virtual volumes prior to implantation for
inverse treatment preplanning [36], and for this
purpose, transverse ultrasound (US) images of the
prostate, urethra, and anterior rectal wall are
acquired in real time. Three-dimensional (3D)
volumes are reconstructed based on a 0.1 cm
image distance. The planning target volume
(PTV) encompasses the entire prostate gland and
the contour definition for the rectum extends cranially (e.g., 1.0 cm) from the prostatic base and
caudally (e.g., 1.0 cm) from the prostatic apex.
Urethra contouring encounters the intraprostatic
urethra marked by the insertion of a radiopaque
three-way Foley catheter and extends caudally (at
least 0.5 cm) to include the apical membranous
urethra. Bladder contouring encompasses the volume visible on US. Based on the acquired 3D
anatomy, appropriate virtual catheter positions are
generated, catheter source dwell positions located
within the PTV are activated, and radioactive
source dwell times are calculated using an intraoperative treatment planning system (Fig. 1). The
final evaluation of the anatomy-oriented dose
optimization [35] is based on the dose-volume
histogram (DVH) of the PTV and the OARs (i.e.,
intraprostatic urethra, anterior rectal wall, and urinary bladder). If the preplanning dosimetry
parameters fulfill the dosimetric protocol, TRUSguided implantation is performed at the previously determined catheter positions (Fig. 2). In
MRI-based implantation, catheter placement is
323
Fig. 1 Three-dimensional reconstruction of the prostate,

urethra, rectum, and bladder with ideal template catheter
trajectories for TRUS-guided implantation as calculated
for preplanning by the real-time treatment planning
system SWIFT/Oncentra Prostate (Nucletron an Elekta

Company, B.V., Veenendaal, The Netherlands). The
virtual perineal template is displayed on the right side
also performed transperineally with the patient in

left lateral decubitus position utilizing a template
device. Similar to the workflow of TRUS-guided
implantation, the MRI-guided procedure includes
a preplanning step based on 3D image volumes
acquired by preinterventional MRI sequences of
at least 0.3 cm slice thickness. The number, distribution, and distance between the catheters are
determined by the preplanning which calculates
the peripheral catheter arrangement with arbitrary
optimization for target coverage. Catheter implantation with control of maximum insertion depth
and positional verification of the implanted catheters is performed by interactive MRI scanning.
commonly performed using either TRUS [911,

80] or CT imaging [17, 18, 8183]. In addition,
MRI-based treatment planning with or without
MRI-guided implantation has also been implemented in clinical practice [77, 78, 84, 85].
3.2
Imaging for Treatment

Planning
After completion of the catheter implantation

procedure, an adequate image series is acquired
for the process of treatment planning. Treatment
planning after TRUS-guided implantation is most
3.2.1
Ultrasound-Based
Intraoperative Treatment
Planning
For US-based intraoperative treatment planning
after TRUS-guided implantation, a series of
TRUS images are acquired with the patient
remaining in lithotomy position. For accurate
anatomic delineation and catheter reconstruction,
image acquisition in steps of as low as 0.1 cm
may be used (Fig. 3ac). Modern systems allow
the continuous movement of the US probe (manually or motorized) without discrete stepping,
where US images are automatically grabbed at a
predefined interval (0.10.5 cm). At this point,
attention should be paid when using standoffs for
a better coupling of sound-avoiding materials,
such as silicone, where geometric shifts are
N. Tselis et al.
324
3.2.2
Fig. 2 High-resolution template with implanted

interstitial steel catheters (20 cm length, 0.19 cm
diameter). The transducer probe for TRUS guidance is
attached to a floor-mounted stepping unit and inserted into
the rectum. A thin intestinal tube for the discharge of
intestinal gases is inserted laterally to the probe and partly
visible behind the lower right angle of the template
observed due to the differences in sound speed

between silicone and soft tissue (981 m/s in silicone versus 1540 m/s in soft tissue) [86].
Alternatively, rotational acquisition can be used
whenever this is supported by the intraoperative
planning system. The extension of the scanning
should be adjusted in such a way that:
The whole prostate gland is included
Possible extensions (e.g., seminal vesicles)
are covered
The tip of all catheters is included
An adequate extension caudally from the
prostatic apex to account for delineation of the
apical membranous urethra (at least 0.5 cm) is
considered
An adequate extension cranially from the
prostatic base and caudally from the prostatic
apex for delineation of the rectum or rectal
wall (e.g., 1.0 cm) is considered
CT- or MRI-Based Postoperative

Treatment Planning
For CT- or MRI-based treatment planning after
TRUS-guided implantation, the patient must be
transferred after recovery from anesthesia to a
CT or MRI scanner, respectively. For accurate
anatomy delineation and reproducible catheter
reconstruction, an image acquisition with slice
thickness of 0.3 cm is recommended.
Considering the craniocaudal scanning extension
for adequate inclusion of the OARs, the
specifications listed above for the US-based
planning procedure should be considered. Since
in current clinical practice two-dimensional dose
calculation is the standard method (TG 43
formalism without consideration of tissue
inhomogeneities and influence of the finite size
of the body) [87, 88], it is not necessary to include
the patients body contour for treatment planning
purposes. For a more accurate delineation of the
prostate, MRI and CT co-registration can be
considered [8991]. Alternatively, only MRI can
be used where both T1- and T2-weighted images
should be considered for an optimal visualization
of anatomy and catheter position [77, 78, 84, 85].
In contrary to the totally TRUS-based clinical
workflow, CT- or MRI-based planning bears an
additional risk for catheter rearrangement and
target volume changes due to transferring of the
patient to a CT or MRI scanner which constitutes
a deviation of the patient setup [9294].
Irrespective of the imaging modality for
interventional guidance or treatment planning,
HDR irradiation is performed using a remote
afterloading system. Iridium-192 is the most
commonly used isotope with an effective energy
of 398 keV, a half-life of 73.81 days, and a half
value layer of 3.0 mm of lead [95].
3.3
Treatment Planning
Postimplantation
image-guided
treatment
planning in temporary HDR prostate BRT
encompasses the steps of anatomy definition,
localization of the implanted catheters, and
dosimetric
calculations
including
dose
optimization.
325
Fig. 3 Impact of different intervals in the ultrasoundbased image acquisition using the transversal crystal array
and continuous movement with a BK medical ultrasound
system (BK medical, Analogic Corporation, USA) and
the Oncentra Prostate planning system: (a) 0.5 cm interval, (b) 0.3 cm interval, and (c) 0.1 cm interval. The superior quality of the reconstructed coronal (left) and sagittal
(middle) images is clearly demonstrated
3.3.1 Anatomy Denition

Even though the concepts of target volumes and
OARs were formalized by ICRU Report 50 [96,
97], BRT practitioners have reported different target and treatment philosophies in the literature [9,
12, 98100]. In order to develop consistency in
target and volume definition for temporary HDR
prostate BRT, the following should be considered

for postimplantation treatment planning independent of the acquired imaging modality [58]:
Clinical target volume (CTV) is defined by:
The prostate capsule plus any macroscopic
extracapsular disease or seminal vesicle
N. Tselis et al.
326
involvement identified on diagnostic

images expanded by 0.3 cm to encompass
potential microscopic disease
Gross tumor volume (GTV) may be defined
using information from previous diagnostic
imaging. Clinical target subvolumes may
include boost volumes to the peripheral zones
or other sites defined from imaging where significant tumor volumes are considered.
Organs at risk should include as a minimum:
Rectum: outlining of the outer wall alone is
considered adequate for BRT dosimetry as
defined for LDR seed techniques.
The urethra using the urethral catheter as a
landmark on imaging for the urethral
contour which should extend from bladder
base to 0.51.0 cm below the prostatic
apex.
Other OARs may include penile bulb, bladder
neck, and the neurovascular bundle.
Consideration should be given to expand the
CTV to define a PTV accounting for any
uncertainties in the procedure, for example,
catheter tracking and image registration.
Catheter Localization
and Optimization
The identification of the tip and thereby of the
first (most distal) source dwell position for each
implanted catheter is essential for the accuracy
of the catheter localization process. Due to the
partial volume effect of all imaging modalities
(US, CT, and MRI), special attention has to be
paid. Kim et al. [101] demonstrated that for
CT-based HDR prostate BRT planning, a CT
slice thickness of maximum 0.3 cm should be
used in order to keep the average dose uncertainty acceptable (i.e., 1.0 % or less). The same
can be transferred to MRI-based treatment
planning [77, 78, 85]. For US-based treatment
planning, advanced tools have been developed
and are available in dedicated treatment planning systems. In general, the US-based process
for catheter tip identification uses the known
physical length of the catheter and the measurement of the catheter free length which is the
portion from the end of the catheter (outside the
body) to the proximal side of the perineal template [102].

It is widely established in clinical practice that
the use of the inverse optimization tools available
in modern treatment planning systems for
automatically adjusting the dwell times of the
source at the different dwell positions of the
catheters should be used [103] (Fig. 4a, b). To
this end, appropriate dose-volume objectives
(objective functions) for the different volumes of
interest (PTV, OARs) and their relative
importance (penalties or importance factors,
Fig. 5) need to be preset. The results of the inverse
optimization depend strongly on concrete
algorithmic implementation. This is also valid for
the influence of the relative importance of the
defined dose-volume objectives on the
optimization result. Specific sets of parameter
values for the specific inverse optimizer and the
specific clinically implemented implantation
technique can be defined to achieve dose
distributions fulfilling, in the best possible way, a
specific dosimetric clinical protocol (Fig. 6ad).
These sets can be stored and are available for
each new planning process, thus improving
efficacy and reproducibility.
3.3.2
3.3.3
Dose Prescription and Dose

Fractionation Schemes
In spite of the high sensitivity of the minimum
dose (MD) or minimum peripheral dose (MPD)
to small delineation inaccuracies in the PTV, in
both the ABS consensus guidelines [57] and the
ESTRO recommendations [58], the aimed or
intended MPD to the PTV is referred to as the
prescribed dose for the treatment. In this context,
the majority of the relevant literature refers to
planned dose to the achieved D90-values for the
PTV. Those values are more stable regarding
delineation inaccuracies and resolution of the
calculation grid or number of sample points than
the MD values. In general, it should be distinguished between the aimed or intended dose
(prescription) and the realized dose in the planning process. In other words, the aimed D90-value
for the PTV (usually at least the aimed dose)
should be distinguished from the planned D90value which is the value that is delivered in the
327
Fig. 4 Intraoperative real-time TRUS-based treatment

planning. (a) Three-dimensional reconstruction of the
prostate, organs at risk (i.e., rectum, urethra, bladder), in
situ catheters, and the source dwell positions as calculated
using the real-time treatment planning system SWIFT/
Oncentra Prostate for the final treatment plan; (b) isodose
distribution after anatomy-based dose optimization. The

isodose color code convention is dark red = 300 %
{isodose = 28.5 Gy}, orange = 200 % {isodose =19.0 Gy},
yellow = 150 % {isodose = 14.25 Gy}, green = 125 %
{isodose = 11.87 Gy}, turquoise = 100 % {isodose = 9.5
Gy}, and dark blue = 50 % {isodose = 4.75 Gy}
Fig. 5 An example of graphical user interface for defining the different parameter values for inverse treatment plan
optimization. In this case, the HIPO-Optimizer (Pi-Medical Ltd., Athens, Greece) as implemented in Oncentra Prostate
N. Tselis et al.
328
individual treatment and represents the individual

dose prescription. For example, White et al. [34]
reported their dosimetric analysis of 104 consecutive patients (208 temporary HDR implants)
treated at the California Endocurietherapy Cancer
Center (CET). The authors could demonstrate
very high reproducibility of the planned (prescribed) D90-value for the PTV. On average, the
planned D90-value was 9.2 % higher than the
aimed dose and thus 9.2 % higher than the dose
per fraction described by the authors in the two
different fractionation schemes which were used
(7.25 Gy and 6.0 Gy per fraction). This is the
result of the specific implantation and optimization technique used at the CET and has to be
taken into consideration when comparing different fractionation schemes. In a similar analysis,
the Offenbach group evaluated 120 consecutive
HDR monotherapy treatment plans. With an
aimed D90 for the PTV of 11.5 Gy per fraction,
the authors showed that the average planned D90
was 102.5 2 % of the aimed value (Fig. 7).
a
Fig. 6 Results of inverse

optimization with Oncentra
Prostate RTP using HIPO
for a CT-based treatment
plan of HDR prostate
BRT. The isodose line
overlay to (a) the central
axial plane (reference
plane), (b) a coronal plane,
and (c) a representative
sagittal plane (d) shows the
corresponding DVH curves
for the PTV, urethra, and
rectum. One hundred
percent corresponds to the
aimed dose prescription
Thus, based on the current Offenbach protocol

[9], the planned dose prescription per fraction,
expressed as D90, is on average 11.8 Gy, and the
total dose achieved in three fractions is on average 35.4 Gy with intended doses of 11.5 Gy and
34.5 Gy, respectively. In comparison, for the CET
monotherapy protocol, the corresponding values
are on average 7.9 Gy per fraction, and the total
dose achieved is 47.4 Gy in six fractions with
intended doses of 7.25 Gy and 43.5 Gy, respectively. Independent of the specific aspects concerning the issue of dose prescription, the
heterogeneity in clinically implemented dose
fractionation schemes makes the establishment
of absolute guidelines for total physical prescription doses and normal tissue dose constraints difficult. For illustration, Table 2 lists dose
fractionation schedules and normal tissue dose
constraints used by various centers. For example,
the William Beaumont Hospital monotherapy
protocol consists of one implant that delivers four
fractions of 9.5 Gy [10]. The current Offenbach
Fig. 6 (continued)
329
Urethra
120
100
D90 V100 V150
D10 D0.1c D1c V100
(58.1 5.3) %
(74.9 2.7) %
(52.5 4.8) %
(98.4 13.2) %
(63.9 9.2) %
20
(114.0 1.3) %
(29.1 3.2) %
40
(92.0 1.6) %
60
(112.9 1.6) %
Rectum
80
(102.5 2.0) %
Fig. 7 Mean values and

standard deviations for
120 consecutive
monotherapy treatment
plans with an aimed D90
for PTV of 11.5 Gy per
fraction for different
dose-volume values for
PTV and OARs. The
values are expressed as
percentage of the aimed
prescription dose of
11.5 Gy to the 90 % of
the PTV
Dose / volume parameter value (%)
Prostate
D10 D0.1c D2c
N. Tselis et al.
330
Table 2 Total physical prescription doses and normal tissue HDR dose constraints (as percent of prescribed reference
dose or absolute dose value) of various treatment schemes
Treatment
protocol
Demanes et al.
2011 [10]a
CET
WBH
Zamboglou et al.
2012 [9]a
Prada et al.
2012 [144]a
Hoskin et al.
2007 [82]b
Kotecha et al.
2013 [14]b
Pistis et al.
2010 [13]b
Morton et al.
2010 [115]b
Agoston et al.
2011 [116]b
PTV
Rectum
Bladder
Urethra
D90
V100
V150
7.0 Gy 6
(42 Gy)
9.5 Gy 4
(38 Gy)
9.5 Gy 4
(38 Gy)
11.5 Gy 3
(34.5 Gy)
19 Gy 1
(19 Gy)
37.7 Gy EBRT +
2 8.5 Gy
(17 Gy) BRT
4550.4 Gy
EBRT + 3
(5.57.5 Gy)
BRT
60 Gy EBRT + 1
9 Gy BRT
1 15 Gy BRT +
37.5 Gy EBRT
4061 Gy EBRT
+ 1 8 or 10 Gy
BRT
D 0.1 cm3
80 %
D 0.1 cm3
75 %
D 0.1 cm3
80 %
D 0.1 cm3
80 %
D 0.1 cm3
75 %
D 2.0 cm3
<6.7 Gy
D 0.1 cm3
80 %
D 0.1 cm3
80 %
D 0.1 cm3
80 %
D 0.1 cm3
80 %
D 0.1 cm3
110 %
D 0.1 cm3
120 %
D 0.1 cm3
120 %
D 0.1 cm3
120 %
D 0.1 cm3
110 %
D 10 <10 Gy
>100 %
>97 %
>100 %
>96 %
100 %
90 %
35 %
100 %
90 %
35 %
D 0.1 cm3
100 %
D 0.1 cm3
120 %
100 %
D 2.0 cm3
75 %
Dmax80 %
105 %
98 %
50 %
Dmax80 %
D 2%
<120 %
Dmax118 %
95 %
40 %
Dmax80 %
Dmax125 %
95 %
Abbreviations: D10 dose delivered to 10 % of the organ, D0.1 cm3 maximum dose to the most exposed 0.1 cm3 of the organ,
D2.0 cm3 maximum dose to the most exposed 2.0 cm3 of the organ, D2% maximum dose to the most exposed 2 % of the
organ, Dmax maximum dose to the most exposed points of the organ, V100, V150 percent of PTV receiving 100 % and 150 %
of the prescription dose, CET California Endocurietherapy Cancer Center, WBH William Beaumont Hospital
a
Monotherapy
b
Combined treatment with supplemental EBRT
monotherapy protocol consists of three implants

each delivering one fraction of 11.5 Gy with
implants separated by 21 days [9]. At the Catalan
Institute of Oncology, combined treatment is
delivered with 60 Gy conventionally fractionated
EBRT followed by a single-fraction HDR boost
of 9 Gy within 21 days [13].
Clinical Data
4.1
HDR Boost in Combination

with EBRT
In patients with intermediate- and high-risk prostate cancer, dose-escalated RT has been shown to
improve both BC and LC [4, 5, 24, 25, 2729,

104107]. The combination of EBRT and HDR
BRT allows for the safe delivery of escalated biologic equivalent doses to the prostate not achievable in terms of conformality even by
image-guided IMRT [3, 108111]. Two randomized trials have helped to show the superiority of
HDR BRT combined with EBRT over EBRT
alone in the radical treatment of localized prostate cancer. Sathya et al. [112] assigned 104
patients to conventional EBRT of 66 Gy in 33
fractions or to 35 Gy HDR BRT with supplemental EBRT of 40 Gy in 20 fractions. At a median
follow-up of 8.2 years, the authors reported biochemical failure in 17 patients of the combined
arm compared with 33 patients in the EBRT
alone arm (p = 0.0024). Overall survival was 94

% in the combined arm versus 92 % in the EBRT
arm without statistically significant differences in
acute or late genitourinary (GU) and gastrointestinal (GI) toxicity. In an analogous approach,
Hoskin et al. [82] randomized 220 patients to
either hypofractionated EBRT alone or hypofractionated EBRT combined with HDR BRT. The
EBRT group (n = 111) received 55 Gy in 20 fractions, whereas the combined treatment group
(n = 109) was given 35.75 Gy EBRT in 13 fractions plus a 17-Gy HDR boost applied in two
fractions. The mean biochemical failure-free survival in the combined arm was 5.1 vs. 4.3 years in
the EBRT-only group (p = 0.03) without statistically significant differences in higher-grade GU
and GI toxicity. The results of these randomized
trials are in accordance with the oncological outcomes reported in large retrospective series [13
15]. Kotecha et al. [14] treated 229 patients with
an HDR BRT boost followed by EBRT. The
boost consisted of three fractions of HDR BRT at
5.57.5 Gy per fraction and supplemental EBRT
of conventionally fractionated IMRT delivering
45.050.4 Gy. The generated BED1.5 values
ranged from 171 to 226 Gy with a median value
of 191.5 Gy. The 7-year biochemical relapse-free
survival rates were 95 %, 90 %, and 57 % for
low-, intermediate-, and high-risk patients,
respectively, with a 7-year BC of 81 % among
high-risk patients with BED1.5 values >190 Gy.
The reported incidence of late Grade 3 GU and
GI toxicity was 3.1 % and 0.4 %, respectively. In
a scheme consisting of EBRT interdigitated with
HDR BRT, Prada et al. [15] reported on 252 highrisk patients treated with 46 Gy EBRT and two
fractions of HDR BRT of 10.511.5 Gy yielding
total combined BED1.5 doses ranging from 292 to
366 Gy. The accomplished 5- and 10-year BC
rate was 84 % and 78 %, respectively, with 2.7 %
late Grade 3 GU and no late GI toxicity.
Although the heterogeneity of clinically
implemented treatment schemes makes uniform
recommendations concerning the optimal
combined treatment protocol challenging, the
published oncological results on HDR BRT
combined with supplemental EBRT are consistent
and reproducible (Table 3). Most authors use
BRT fractions ranging from 6 to 10 Gy yielding
331
total physical HDR doses of 1220 Gy applied in

two to four fractions. The supplemental EBRT
doses range from 45 to 54 Gy, generating total
BED1.5 and EQD2 doses in the range of 171
366 Gy and 74137 Gy, respectively [1215, 17,
18, 54, 79, 81, 99, 112117, 119121, 123127].
The reported rates of severe late GU and GI
adverse events compare favorably with late
toxicity rates in dose-escalated EBRT series
[105, 128130].
4.2
HDR Monotherapy
Although HDR BRT was initially used as a boost

modality in conjunction with EBRT because of
concerns about the normal tissue toxicity of
hypofractionated treatment regimes, dose
escalation studies established the safety and
efficacy range for HDR in the context of
combined EBRT and BRT [17, 131, 132]. These
clinical experiences, together with technological
advances in real-time image guidance and 3D
image-based treatment planning, led to the
introduction of HDR monotherapy as a
conceptually comprehensible RT approach for
organ-confined prostate cancer [132134]. The
rationale for HDR monotherapy was derived
from other locally directed treatments such as
radical prostatectomy, definitive EBRT, and
permanent LDR seed monotherapy considering
that image-guided HDR with anatomy-based
dose optimization can reliably treat the prostate
and simultaneously control the dose to adjacent
OARs [20]. There is by now a growing body of
literature that corroborates HDR monotherapy as
a safe and effective modality for the radical treatment of localized prostate cancer with consistent
intermediate- and long-term BC rates reported
for all risk groups [911, 20, 22, 69, 76, 80, 132,
135144]. Although direct comparisons are difficult, given the variety of clinically implemented
dose fractionation schemes, the oncological outcomes yielded with single- or multiple implant
regimes for extreme hypofractionated or multifractionated treatment protocols are uniform
(Table 4).
Kukielka et al. [140] reported the oncological
outcomes in 77 patients of various risk groups
N. Tselis et al.
332
Table 3 Literature results of HDR BRT as boost modality to EBRT for clinically localized prostate cancer
144
Treatment scheme
Total EBRT dose Total HDR Total BED/
(Gy/fx)
dose (Gy/fx) EQD2 (Gy)
40/20
18/2
219/94
Follow-up
(years)
Median 8.2
114
60/20
9/1
203/87
Mean 2.7
229
4550.4/2528
16.522.5/3
171226/7497
Median 5.1
102
45/25
2028/4
Median 2.6
252
46/23
2123/2
214
50/25
20/2
191251/82
108
292366/109
137
269/116
207
46/23
16.523/2
3
184306/79
131
Mean 4.4
Noda et al.
[114]
59
50/25
1518/2
191243/82
104
Median 5.1
Hoskin et al.
[82]
Morton et al.
[115]
Agoston
et al. [116]
220
35.75/13
17/2
214/92
Median 2.5
123
37.5/15
15/1
265/114
Median 1.2
100
4060/2030
8/1 or 10/1
144219/6694
Median 5.1
Hiratsuka
et al. [117]
Pellizzon
et al. [119]
71
41.8 /19 or 45/25

3654/2030
176206/92
110
143237/5994
Median 3.6
209
16.5/3 or
22.5/4
1624/4
Phan et al.
[120]
309
39.650.4/2028
15-26/3-4
144218/6397
Median 4.9
Viani et al.
[121]
131
4550/25
1624/46
158237/67
101
Median 5.2
n
Study
Galalae
et al. [81]
Pistis et al.
[13]
Kotecha
et al. [14]
Martin et al.
[79]
Prada et al.
[15]
strm et al.
[113]
Martinez
et al. [17]
Median 6.1
Median 4
Median 5.3
Biochemical controla
74 %/69 % all risk
groups at 5years/8 years
97.4 % IR and HR at 4
years
95 % LR at 7 years,
90 % IR at 7 years, 57 %
HR at 7 years (81 % HR
with BED > 190 Gy)
100 % LR/IR at 3 years,
79 % HR at 3 years
84 %/78 % HR at 5
years/10 years
82 % all risk groups at 5
years
52 % all risk groups for
EQD2 < 93 Gy and 87 %
all risk groups for
EQD2 > 93 Gy at 5 years
100 % LR at 5 years,
92 % IR at 5 years, 72 %
HR at 5 years
Mean for all risk groups
4.3 years
100 % all risk groups
85.5 % all risk groups at
5 years with IR 84,2 %
at 7 years and HR
81,6 % at 7 years
93 % at 5 years (ASTRO
definition [118])
94.2 % all risk groups at
3.3 years with 91.5 %
LR, 90.2 % IR, and
88.5 % HR
86 % all risk groups at 5
years with 98 % LR,
90 % IR, and 78 % HR
(ASTRO definition
[164])
81 % at 5 years with
87 % IR and 71 % HR
Abbreviations: LR low-risk group, IR intermediate-risk group, HR high-risk group, y years, BED biologically effective
dose considering an a/ ratio for prostate cancer of 1.5, EQD2 biologically effective dose administered in 2Gy fractions
a
Biochemical failure defined by the Phoenix definition [122] unless specified otherwise
who were treated with 45 Gy in three singlefraction implants at 15 Gy. The 5-year overall
survival was 98.7 % with an actuarial BC rate of
96.7 %. There were no acute Grade 3 or higher

toxicities; however, acute Grade 2 GU toxicity
was seen in 25 % of patients. One patient experi-
333
Table 4 Literature results of HDR BRT as monotherapy for localized prostate cancer
HDR protocol
Study
Yoshioka et al.
[76]
n
111
Gy/fraction
6.0 Gy
Yoshioka et al.
[56]
63
6.5 Gy
Hoskin et al.
[11]
197
8.59.0 Gy
10.5 Gy
13.0 Gy
Fractions
(implants)
9 (1
implant)
Total
54 Gy
Median
f/u (y)
5.4
Biochemical
controla
93 % IR,
85 % HR at 3
years
96 % IR,
90 % HR at 3
years
95 % IR,
87 % HR at 4
years
BED
(Gy)
270
EQD2
(Gy)
116
7 (1
implant)
45.5 Gy
3.5
243
104
4 (1
implant)
3 (1
implant)
2 (1
implant)
6 (2
implants)
6 (2
implants)
3436 Gy
4.55
227
252
97
108
31.5 Gy
26 Gy
0.5
39 Gy
94 % IR at 5
years
88 % all risk
groups at 8
years
100 % LR,
88 % IR at 32
months
97 % LR/IR at
5 years
208
89
45 Gy
270
117
260
111
238
279
102
119
4.4
95 % LR,
93 % IR 93 %
HR at 5 years
279
299
119
128
38
279
119
3034.5
3.3
45.5
1.4
100 % LR/IR
at 3 years
85.1 % LR/IR
at 5 years
94 % all risk
groups at 17
months
230
299
243
99
128
104
Rogers et al.
[69]
Mark et al.
[141]
284
6.5 Gy
301
7.5 Gy
Prada et al.
[144]
40
19.0 Gy
1 (1
implant)
19 Gy
1.6
Demanes et al.
[10]
298
7.0 Gy
6 (2
implants)
4 (1
implant)
4 (1
implant)
4 (2
implants)
3 (3
implants)
4 (1
implant)
3 (1
implant)
7 (1
implant)
42 Gy
5.2
9.5 Gy
Zamboglou
et al. [9]
718
9.5 Gy
9.5 Gy
11.5 Gy
Ghadjar et al.
[137]
Barkati et al.
[135]
Komiya et al.
[139]
36
9.5 Gy
79
10-11.5 Gy
51
6.5 Gy
38 Gy
38 Gy
38 Gy
34.5 Gy
Abbreviations: LR low-risk group, IR intermediate-risk group, HR high-risk group, f/u follow-up, y years, BED
biologically effective dose considering an a/ ratio for prostate cancer of 1.5, EQD2 biologically effective dose
administered in 2Gy fractions
a
Biochemical failure defined by the Phoenix definition [122]
enced late Grade 3 urethral stenosis with no late

Grade 3 GI adverse events detected. Mark et al.
[141] reported an actuarial BC rate of 88 % at 8
years in 301 patients of all risk groups treated
with two implants at three fractions of 7.5 Gy.
Acute urinary retention occurred in 5 % of
patients with late Grade 34 GU adverse events
in 6 %. Late GI toxicity was Grades 12 in 2.3 %

and Grades 34 in 0.3 % of patients. Similarly,
Rogers et al. [69] reported their experience on
284 patients with intermediate-risk prostate cancer treated with two implants to deliver six fractions of 6.5 Gy. The 5-year actuarial BC was
94.4 % with MFS of 99 %. Unlike other reports,
334
there were no Grade 3 urethral strictures with

late Grade 12 GI toxicity in 4.2 % of patients.
All authors included clinical stages T2b with
no exclusions for Gleason score (GS) or pretreatment prostate-specific antigen (PSA) in the
series by Mark et al. [141] and Kukielka et al.
[140]. These data corroborate the clinical experience of other groups indicating that HDR BRT is
applicable for monotherapy over a range of risk
groups including intermediate- and selected
cases of high-risk disease [9, 11, 76, 139, 145,
146]. Hoskin et al. [11], for example, conducted
a dose escalation trial of 197 patients with predominantly intermediate- (52 %) and high-risk
(44 %) cases. The implemented monotherapy
protocols consisted of 34 Gy in four fractions,
36 Gy in four fractions, 31.5 Gy in three fractions, or 26 Gy in two fractions. The authors
reported a 4-year BC rate of 87 % for the highrisk group which included clinical tumor
stages T3 in 21 %, GS 8 in 10 %, and
PSA > 20 ng/ml in 25 % of patients with 92 % of
cases receiving temporary ADT. The incidence
of acute Grade 3 GU morbidity was 37 % with
no cases of acute GI toxicity. Late Grade 3 GU
toxicity was 316 % with late Grade 3 GI toxicity documented in 1 % of patients. Similar results
were reported by Zamboglou et al. [9] who
treated 718 consecutive patients utilizing three
different monotherapy protocols (four fractions
of 9.5 Gy in one implant, four fractions of 9.5 Gy
in two implants, and three fractions of 11.5 in
three implants). The study population included
44.9 % of intermediate- and high-risk patients
with clinical tumor stages > T2b in 13 %,
GS 7 in 23 %, and PSA > 11 ng/ml in 7.3 % of
all patients. Almost 60 % of high-risk and 27 %
of intermediate-risk cases received temporary
ADT including all patients with PSA 20 ng/ml,
93 % of patients with GS 7b (4 + 3), and more
than 90 % of cases staged > T2b. The 5-year BC
rate for intermediate- and high-risk patients was
93 % and 93 %, respectively. The authors documented 3.5 % late Grade 3 GU and 1.6 % late
Grade 3 GI adverse events with two patients
developing Grade 4 urinary incontinence and
two patients requiring endoscopic restoration of
bowel continuity.
N. Tselis et al.
Data on erectile function after HDR monotherapy have been rarely reported using various multidimensional or ordinal scales for assessment.
However, potency preservation rates of 7590 %
are documented in the recent literature [9, 69,
139, 143, 144, 147, 148]. Komyia et al. [139]
evaluated the quality of life (QOL) in 51 patients
of various risk groups who were treated with one
implant in seven fractions of 6.5 Gy. Long-term
adjuvant ADT was used for high-risk cases.
Assessment of QOL included the International
Prostate Symptom Score (IPSS) [149] and the
International Index of Erectile Function (IIEF)
[150] questionnaire. The total IPSS increased significantly at 2 and 4 weeks after BRT but recovered to pretreatment values by 12 weeks in all
patients. The erectile function was significantly
impaired at 2 and 4 weeks after BRT in patients
without ADT; however, it recovered to pretreatment values by 12 weeks with an IIEF score >21
points. Ghadjar et al. [147] reported on 36 patients
with low- and intermediate-risk prostate cancer
treated with one implant in four fractions of
9.5 Gy. Fourteen percent of patients received concomitant ADT. At a median follow-up of 6.9
years, 19 % of patients experienced late Grade 3
GU adverse events with no late Grade 23 GI toxicities. The crude erectile function preservation
rate in patients without ADT was 75 %.
So far, no randomized trial has ever compared
LDR and HDR monotherapy, but nonrandomized
evaluations have confirmed that both acute and
late high-grade toxicities are less frequent after
HDR than LDR monotherapy [138, 143].
Martinez et al. [143] performed a comprehensive
toxicity comparison between 248 HDR monotherapy and 206 LDR seed patients. The 5-year
actuarial BC for monotherapy was 88 % for HDR
and 89 % for seeds with no difference in cancer
mortality or overall survival. Temporary HDR
monotherapy was associated with significantly
less Grade 12 chronic dysuria (LDR 22 % vs.
HDR 15 %) and urinary frequency/urgency (LDR
54 % vs. HDR 43 %). The rate of urethral stricture was equal with 2.5 % for LDR vs. 3 % for
HDR. Chronic Grade 3 GU toxicity was low in
both groups with about 2 % for HDR, mostly urinary frequency/urgency. The 5-year potency
preservation rate was 80 % for HDR and 70 % for

permanent LDR BRT.
Overall, the clinical outcome data of HDR
monotherapy reflect current radiobiological considerations for optimal tumor control through
hypofractionation. The BED values in Table 4
range from 208 to 299 Gy with a median value of
256 Gy, considering an alpha/beta ratio of 1.5 Gy.
However, even for an alpha/beta ratio of 3.0 Gy,
the BED values would be in the range of 123
167 Gy. In comparison with LDR implants,
where attempts are made to attain a BED > 200 Gy
by mainly adding EBRT [151, 152], HDR
monotherapy generates BED values far higher
than 200 Gy by itself. The values for EQD2 in
Table 4 range from 89 to 128 Gy for an alpha/
beta ratio of 1.5 Gy (77104 Gy for an alpha/beta
ratio of 3.0 Gy) which may be mostly impossible
to administer with conventional EBRT. In
contrast to clinical data from definitive EBRT,
however, the potential advantage of temporary
ADT for patients treated with HDR monotherapy
remains an issue of ongoing discussion as no
corroborative evidence exclusive to this modality
exists [20, 153].
The excellent results of HDR prostate BRT
have prompted the implementation of stereotactic
body radiotherapy (SBRT) for the percutaneous
treatment of localized prostate cancer using
extreme hypofractionation and utilizing continuous image guidance to automatically track, detect,
and correct for intrafraction prostate movement
[154158]. It appears to represent a biologically
potent local treatment method, seemingly combining EBRT-like noninvasiveness with HDR
BRT-like biologic potency [159]. However, in a
recent dosimetric analysis comparing virtual
SBRT with actual HDR monotherapy plans from
treated patients, Spratt et al. [160] demonstrated
that HDR achieves significantly higher intraprostatic doses while achieving similar urethral doses
and lower maximum rectal doses compared with
virtual SBRT treatment planning. Although SBRT
has the potential to recapitulate HDR dosimetry
[161], at present, there are no durable monotherapy outcome data and no direct clinical trials
comparing temporary HDR, permanent LDR, or
SBRT in the treatment of prostate cancer. In addi-
335
tion, given the tight surgical margin associated

with SBRT, it is not recommended for more
advanced disease such as extracapsular extension
or seminal vesicle involvement [156, 162].
4.3
HDR Monotherapy as Salvage

Treatment
The ideal management of patients experiencing a

biochemical recurrence (BCR) after radical RT
for clinically localized prostate cancer remains a
controversial clinical issue [163]. Despite the primary treatment-related variation in the definition
of BCR [118, 122], clinical data suggest that up to
70 % of patients with a rising PSA will have local
disease as the only demonstrable site of recurrence [164166]. Therefore, repeat local treatment poses a comprehensible therapeutic
approach with different local procedures such as
salvage radical prostatectomy, salvage high-intensity focused US, and salvage RT being clinically
practiced [167]. For pathologically proven local
failure after previous definitive RT, salvage HDR
BRT (sHDR BRT) with or without ADT appears
to be an effective, well-tolerated treatment option
with disease control and toxicity rates which compare favorably to those reported using other nonradiotherapeutic local treatment modalities [165,
168173]. Lee et al. [168] treated 21 patients
(median pre-salvage PSA 3.8ng/ml with median
pre-salvage GS 7) after primary EBRT of a
median 66.6 Gy with 36 Gy sHDR BRT in six
fractions using two TRUS-guided implants separated by 1 week. The reported BC at median 18.7
months of follow-up was 89 % with 86 % Grade 2
and 14 % Grade 3 GU adverse events at 3 months
after BRT. Yamada et al. [173] reported the results
of a Phase II study of 40 patients (median presalvage PSA 3.45ng/ml with 60 % GS 7 and 33 %
GS 8) treated with sHDR BRT after prior definitive EBRT. The protocol prescription dose of
32 Gy was delivered in four fractions of 8 Gy over
30 hours. Twelve patients had neoadjuvant
ADT. At a median follow-up of 38 months, the
estimated PSA disease-free survival was 70 %.
Late Grade 1 and 2 GU toxicities were found in
38 % and 48 %, respectively, with one patient
336
developing Grade 3 urinary incontinence. Late

Grade 1 and 2 GI toxicity was noted in 17 % and
8 % of patients, respectively. Three patients developed urethral strictures requiring urethral dilatation. No Grade 4 toxicities were observed.
Similarly, Oliai et al. [169] reported on a group of
22 patients who underwent sHDR BRT with or
without ADT after primary treatment with EBRT,
LDR BRT, or HDR BRT with supplemental
EBRT, receiving for salvage 36 Gy HDR BRT in
six fractions using two TRUS-guided implants. At
a median follow-up of 45 months, the generated
BC rate was 75 %. Urethral strictures requiring
transurethral resection developed in 32 % of
patients and Grade 2 hematuria manifested in 18 %
of patients. In the series by Chen et al. [165],
which is the largest series of patients treated with
sHDR BRT after previous definitive RT, fifty-two
patients were analyzed. After pathologic confirmation of locally recurrent disease, patients
received 36 Gy HDR BRT in six fractions of 6 Gy.
Median follow-up was 59.6 months with an actuarial BC rate of 51 % at 5 years. Acute and late
Grade 3 GU adverse events were reported in 2 %
and 2 % of patients, respectively. No Grade 2 or
higher acute GI adverse events and 4 % late Grade
2 GI toxicity were documented. In summary,
sHDR BRT for locally recurrent disease after initial radical treatment appears as a promising RT
approach with an acceptable acute and late toxicity profile.
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Lower Gastrointestinal
Brachytherapy: Rectum
Maria Antonietta Gambacorta, Maura Campitelli,
Rezarta Frakulli, Andrea Galuppi,
Alessio G. Morganti, and Vincenzo Valentini
Abstract
The management of rectal cancer is largely surgical. The treatment can be

modulated according to tumor presentation: endoscopic excision and surgery for early tumors, radiotherapy and chemotherapy treatments integrated
to definitive surgery, and, in advanced cases, chemotherapy, palliative surgery and/or radiotherapy, or a combination of the above in metastatic tumors.
Introduction
Population-based studies showed improved overall outcomes from the 1990s and beyond [1].
However, although the improvement in survival
was gained in younger patients, the same result
was not reached for the older (>75 years) group.
M.A. Gambacorta, MD M. Campitelli, MD

V. Valentini, MD (*)
Gemelli ART (Advanced Radiation Therapy),
Catholic University of the Sacred Heart,
Agostino Gemelli Polyclinic, Rome, Italy
R. Frakulli, MD A. Galuppi, MD
A.G. Morganti, MD
Radiation Oncology Center,
Department of Experimental,
Diagnostic and Specialty Medicine-DIMES,
University of Bologna, San Orsola-Malpighi
Hospital, Bologna, Italy
This seems to be due to the lesser access to preoperative treatments and to the higher mortality
rate at 6 months post-TME for older versus
younger patients (14 % vs. 3.3 %) (p < 0.0001)
[2]. Multimodal treatments, especially including
a radical surgery component, may be too demanding for aged, frail patients who more often have
associated comorbidities. Many times patients
with significant medical illnesses cannot tolerate
prolonged anesthesia or morbidity from the surgical approach. This category of patients has
been treated, in some series, with conservative
surgery or radiotherapy alone, with the intent of
either achieving prolonged symptom control or
prolonged tumor control, trying to minimize
treatment-related side effects [35].
Younger or fit patients who undergo radical
TME surgery have impaired quality of life due to
the inevitable consequences of the surgical procedure: patients with ultra-low rectal cancer who
undergo abdominoperineal resection (APR) have to
live with the stoma; patients who undergo low anterior resection (LAR) may suffer from defecation

DOI 10.1007/978-3-319-26791-3_20
345
M.A. Gambacorta et al.
346
problems due to the entire removal of the rectum

and/or anal sphincteric injury. These symptoms
may be more pronounced when radiotherapy is
incorporated, likely related to fibrosis of the surrounding tissue of the neo-rectum and the dysfunction of the anal sphincter, when this is
included in the treatment field [5, 6].
These side effects, although an accepted tradeoff for a cancer cure, may be even more unacceptable for those patients in whom preoperative
radiotherapy +/ chemotherapy results in a pathological complete tumor response (ypCR), and
thus no residual cancer is found in the surgical
specimen after major mutilating surgery leading
many patients and physicians to wonder if the
surgery was really necessary since definitive data
in this circumstance remain elusive.
The achievement of a pCR following neoadjuvant therapy (ypCR), which occurs in approximately 1520 % of patients, has been shown to
reflect better long-term outcomes [79]. These
findings, together with the intention to improve the
quality of life of surviving patients, have stimulated
the exploration of more conservative approaches.
A number of Phase 2 studies are evaluating the role
of conservative treatment in patients who demonstrate substantial clinical response. A completely
nonsurgical or minimal surgical approach with
watch and wait policies after chemoradiotherapy
followed in some series by brachytherapy or local
excision of the residual tumor is being studied following pathological confirmation of clinical
response.
In this setting, decision supportive systems
based on analysis of large data bases, through the
connection of clinical, radiological, and therapy
data, have been created. Nomograms for the prediction of pCR both before surgery and during
chemoradiation are now available. These tools
may support the multidisciplinary team: (1) to
identify the subgroup of patients with an excellent
response after chemoradiation who may benefit
from conservative treatment and (2) to define, during treatment, categories of patients with different
responses, allowing early modulation of preoperative treatment according to response [10, 11].
The definition of prolonged survival in rectal
cancer is enlarging to also include metastatic
patients.
This circumstance represents a complex category including pluri-metastatic patients needing a

systemic approach with the intent to slow the
growth of disease and consequently delay the
appearance of related symptoms. Oligometastatic
disease in some patients now presents an opportunity for salvage cure. In these patients systemic
therapy still represents the main treatment to reach
multiple tumor sites. However, local therapy
directed to the rectum, such as radiotherapy, surgery, or endoscopic strategies, can be considered
according to the aim of the treatment. Eradication
or control of the primary tumor, in those potentially
curable patients or control of tumor-related local
symptoms, such as bleeding, pain, constipation,
and mucous discharge, is now common, while just
a few years ago, this was thought impossible and
not much different from pluri-metastatic disease.
Patients with any or all of the above conditions, age unfit, serious comorbidities, and favorable metastatic patients, may benefit from
conservative therapies such as local excision,
radiotherapy, and brachytherapy, as well as
watch and wait approaches. In these settings,
brachytherapy may play an important role in
increasing quality of life by trying to maintain the
same outcomes of the standard treatment:
1. Achieving cure or long-term control of the
primary tumor, in aged frail and unfit patients,
avoiding surgery
2. Increasing, delivered as a boost, the rate of
ypCR allowing minor or no surgery, in good
responding patients after chemoradiation
3. Achieving symptom palliation related to the
primary tumor in pluri-metastatic patients or
prolonged tumor control in the oligometastatic
patients
Rectal Cancer Brachytherapy

Techniques
Different types of brachytherapy have been used

in rectal cancer and will be briefly summarized in
the following paragraphs: contact X-ray
brachytherapy, high-dose rate intraluminal rectal
brachytherapy, interstitial rectal brachytherapy,
and intraoperative radiotherapy (IORT) [12].
Lower Gastrointestinal Brachytherapy: Rectum
2.1
Contact X-Ray Brachytherapy
With this technique, a high dose of low-energy

(50 KV) X-ray is delivered to the tumor under
direct vision. In France in 1946, Lamarque and
Gros were the first to use the handheld Philips RT
50 machine to treat a rectal cancer [13]. In the
following decades, Papillon popularized this
technique treating more than 300 rectal cancer
patients [14]. The treatment can be delivered as
an outpatient. An empty rectal ampulla is needed,
and therefore a low residue diet for 35 days is
required, and a mini-rectal enema is given 30 min
before the procedure. No general anesthesia is
required and generally only local anesthetic gel is
used. According to the exact tumor site in the
rectum, different treatment positions are
recommended. For anterior and lateral tumor
localization, a knee-chest position helps to open
the rectum and makes it easier to visualize the
tumor. For low posterior tumors, the lithotomy
position is recommended. Initially, a rigid
sigmoidoscope is inserted into the anus and
rectum to identify tumor size and location. Based
on tumor size, the diameter of the applicator is
chosen, inserted, and placed directly to encompass
the tumor with a small margin of about 0.1 cm.
Different sizes of applicators are available: 3.0,
2.5, and 2.2 cm. One hundred percent of the dose
is prescribed at the surface, and the dose falls off
to 60 and 55 % at a 0.5 cm depth for 3.0 and
2.2 cm diameter applicators, respectively. The
dose rate is close to 20 Gy/min and treatment
time does not exceed 13 min. Recently, an
innovative machine, the Papillon 50TM (Ariane
Medical Systems Ltd, Derby, UK), has been
designed allowing direct vision during treatment.
347
general anesthesia is not mandatory and conscious sedation can be substituted if necessary.
Patients are placed into the lithotomy position
and the rectal applicator is inserted following
local anesthetic application. There are two different types of rectal applicators: rectal rigid line
(with or without central shielding) or multichannel. A rectal rigid line applicator is a cylindrical
tube with an outer diameter of 2.0 cm and a length
of 16 cm; it houses a centrally placed stainless
steel catheter (0.3 cm in diameter) as the application channel of the iridium source with spacing
for shielding. This system allows shielding from
25 to 75 % of the applicator circumference for
treatment of tumors with less than complete circumferential mucosal involvement [17]. The
alternative system (multichannel) has the advantage that the catheters can be selectively loaded,
ensuring more conformal dose delivery and sparing the uninvolved opposite rectal wall. The
applicator also contains a balloon, which can be
inflated to immobilize the applicator in the
desired position within the rectum thus reducing
the dose to the normal structures [18]. After
applicator positioning, a computerized tomography scan using 0.5 cm slice thickness is performed for planning. Dwell positions are selected
to accommodate the outlined clinical target volume (CTV). The CTV is defined as the gross
tumor volume (GTV) plus a 0.5 cm margin, and
the dose is normalized to the mean of applicator
points at a distance from the applicator surface,
equidistant between loaded catheters. Sometimes
computerized optimization to achieve acceptable
coverage (such as V100 90 %) may be
necessary.
2.3
2.2
Endoluminal High-Dose-Rate
(HDR) Rectal Brachytherapy
This technique was developed in the 1990s by

Sun Myint in Clatterbridge [15] and Vuong in
Montreal [16]. Both 192Ir- and 60Co-sourced
remote afterloader systems are available. Initially
in the procedure, radiopaque clips are endoscopically inserted to mark the proximal and distal
margins of the tumor. For contact radiotherapy,
Rectal Interstitial Implant
Interstitial implants of the rectum are most

often used as a boost after external beam radiation. Initially endorectal ultrasound is useful to
identify the thickness of the residual tumor.
Patient preparation starts the day before
procedure including perineal shaving and
cleansing enemas. The procedure is performed
under general or spinal anesthesia. Patients are
placed in the lithotomy position and a Foley
348
catheter is inserted into the bladder. Using

guide needles and a template, needles are
sequentially inserted via the perineum approximately 0.30.4 cm from the mucosal surface.
The distance between needles is 1 cm. A 2.5 cm
margin beyond the volume to be covered by
isodose is recommended to take account of all
the variables (the pull back from patients, the
crimped tip, and the tip of sources to the reference isodose using the Paris system). During all
treatments a rectal tube is inserted to keep the
anal canal open and to push the mucosa opposite the implanted needles away from the
defined treated volume. The tube also allows
gas and/or fecal evacuation during treatment. A
compressive dressing is applied to prevent displacement of the system during irradiation.
However, the correct position of the implant
has to be monitored daily [19].
Rectal Cancer Brachytherapy:

Clinical Results
Brachytherapy in the treatment of rectal cancer

has been performed since the 1940s and 1950s
due to the pioneering contributions of Chaoul
[20] and Lamarque and Gros [13] using a
nonsurgical approach on small and accessible
cancers.
In the 1970s, Papillon et al. [21] published his
successful work on endocavitary contact
radiotherapy (CXRT) using 192Iridium interstitial
brachytherapy in the conservative treatment of
152 rectal cancers, obtaining excellent local
control and anal function preservation.
By the end of 1990s, Maingon et al. [22]
reported a complete response rate of 93 % with a
sphincter preservation rate of 84 % and a normal
sphincter function of 98 % in a series of 151
patients affected by T1 to T3 low rectal adenocarcinomas treated by a combination of contact
X-ray, interstitial brachytherapy, and external
beam radiation therapy (EBRT).
In 1992, the Papillion technique was introduced at Clatterbridge in the UK by Sun Myint,
and iridium endoluminal high-dose-rate brachy-
therapy was introduced to Montreal in the 1990s

by Vuong.
A number of studies investigated the role of
brachytherapy as an alternative preoperative
treatment or as a dose escalation procedure,
combined with external radiation therapy in
elderly or inoperable patients or in a preoperative
setting. Their results will be reported here.
3.1

as an Alternative Preoperative
Treatment
In an attempt to reduce the toxicity related to

radiochemotherapy, 100 patients with resectable
rectal adenocarcinoma T2T4, N0/N1 were
treated with a daily dose of 6.5 Gy of endorectal
brachytherapy for over 4 consecutive days at
McGill University [23]. Immediate tolerance was
good in 99 patients who developed no more than
grade 2 acute proctitis. Surgery was performed
48 weeks after the completion of brachytherapy.
Pathologic review demonstrated 29 % of the
surgical specimens with a ypCR, comparing
favorably with responses achieved with
conventional radiochemotherapeutic treatment.
At 5 years, the local recurrence rate was 5 %.
Surgical complications were not increased with
this approach.
Hesselager et al. at Uppsala University in collaboration with Vuong et al. of McGill University
[16, 24] recently published the results related to
short-term complications following rectal resection in T3T4 Nx patients preoperatively treated
with short-course radiotherapy or high-dose-rate
endorectal brachytherapy (HDREBT) or with no
preoperative radiotherapy. The brachytherapy
technique was the same as described above. They
found no major differences in postoperative complications between the groups, with lower rates
of reoperation and perioperative bleeding in the
high-dose-rate brachytherapy group. Complete
tumor regression was obtained in nearly onequarter of patients in the brachytherapy group
with a higher proportion of R0 resection, probably due to a longer interval between radiotherapy
and surgery and the higher total dose delivered to
the tumor bed by brachytherapy. They concluded

that high-dose-rate brachytherapy can be considered a safe alternative to neoadjuvant treatment
for patients with resectable rectal cancer,
although further studies would be needed to
investigate whether a high tumor regression
grade will translate into better local control and
survival.
Smith et al. [25] at Johns Hopkins University
conducted a pilot study on 7 T2 N1 or T3 N0N1
low rectal adenocarcinoma patients, who were
treated
with
high-dose-rate
endorectal
brachytherapy. They were compared with
historical controls treated with conventional
three-dimensional conformal external beam
radiotherapy (3DCRT) or intensity-modulated
radiotherapy (IMRT). They found results in terms
of pCR and toxicity similar to Vuong, with a
trend in favor of HDREBT.
In this context, a careful selection of patients
is fundamental (i.e., N0N1 mesorectal only) for
brachytherapy success.
3.2

as a Dose Escalation
Procedure
Contact X-ray brachytherapy is the only technique whose benefit was proven by a randomized trial, the Lyon R96-02 Phase 3 trial [26].
Between 1996 and 2001, 88 patients with
selected distal rectal cancer (T2 or early T3),
involving less than 2/3 of the rectal circumference, were randomized between preoperative
EBRT (39 Gy in 13 fractions) and the same
EBRT with a CXRT boost of 85 Gy in 3 fractions (35, 30 and 20 Gy in sequence). For
patients with a complete clinical response 4
weeks after the completion of EBRT, a final
boost of 25 Gy could be given to tumor bed
using an interstitial iridium-192 brachytherapy
implant. The main end point was sphincter preservation. The results, published in 2004, demonstrated that CXRT significantly increased the
rate of clinical complete response, pathological
response, and sphincter preservation at a mean
follow-up of 35 months.
349
The 10-year follow-up of the Lyon R96-02

trial described a cumulated colostomy rate of
29 % in the EBRT + CXRT group versus 63 % in
the EBRT alone group (p < 0.001) [27]. The
10-year cumulative colostomy rate according to
clinical response was 17 % in patients who had a
complete clinical response (15 % of total), 42 %
in patients with a clinical response 50 % (68 %
of total), and 77 % in those patients with a clinical
response <50 % (17 % of total) (p = 0.014).
Interestingly, for nine patients with a major/
complete clinical response, the therapeutic
strategy was to perform an organ-saving approach
such as a transanal local excision or other
nonoperative treatment, which contributed to the
improved rate of sphincter saving observed in the
experimental arm. The 10-year rate of local
control, disease-free survival, and overall survival
were similar between the two arms of the trial,
demonstrating that the sphincter preservation did
not compromise control of the disease.
The main limits of this study were the small
number of total patients and the use of
radiotherapy alone without chemotherapy, a
context in which dose escalation should be
evaluated to improve conservative treatment.
The use of rectal cancer brachytherapy as a
boost technique has been evaluated also by Sun
Myint in Clatterbridge [15]. They investigated
whether the addition of a high-dose rate
brachytherapy boost following preoperative
chemoradiotherapy could improve surgical
outcomes in terms of R0 resection and pCR. They
included bulky low non-circumferential or fixed
T2 or T3 resectable tumors with threatened
circumferential resection margin or multiple
suspicious lymph nodes. Thirty-four patients
received 45 Gy to the pelvis over 5 weeks
concurrently with chemotherapy and a 10 Gy
boost at 1.0 cm from the surface of the applicator
68 weeks before surgery. Twenty-nine patients
went on to operation, and among these, 24
achieved an R0 resection (80 %), while nine
(31 %) had a pCR with both rates higher than
those reported in literature. No local recurrence
was observed after a median follow-up interval of
17 months. As regards to toxicity, there was no
increase in grade 34 toxicity and no delay in
350
wound healing or increase in anastomotic leakage

as compared to historic data. The study
demonstrated that increasing the dose of radiation
with an HDR brachytherapy boost appears to
improve the likelihood of obtaining an R0
resection and pCR rate, but the short follow-up
was not sufficient for meaningful survival
analysis.
Despite these encouraging early results on the
improved tumor response at the time of surgery,
the recently published randomized Danish study
on long-term results of brachytherapy boost in
advanced rectal cancer has not been so
enthusiastic [28]. In this study, a cohort of 221
patients T3T4 N0N2 M0 was randomized
between radiochemotherapies with or without a
brachytherapy boost. At a median follow-up of
5.4 years and despite a significant increase in
tumor response at the time of surgery (41 % in
the brachytherapy boost arm versus 27 % in the
standard arm), no differences in 5-year OS
(70.6 % vs. 63.6 %, respectively, hazard ratio
[HR] = 1.24, p = 0.34) and PFS (63.9 % vs.
52.0 %, respectively, HR = 1.22, p = .32) were
observed. Freedom from locoregional failure at 5
years was 93.9 and 85.7 % (HR = 2.60, p = .06) in
the standard and in the brachytherapy arms,
respectively. Unfortunately the trial did not report
data on late toxicity.
The authors concluded that the use of
brachytherapy as a boost treatment for locally
advanced rectal cancer patients in the preoperative
setting cannot be recommended based on the
findings of their trial. On the contrary, the role of
brachytherapy in other patient groups, such as
patients with early rectal cancer treated with
definite radiotherapy (as for patients in the Lyon
R 9602) or patients treated with palliative intent,
remains open.
3.3

in Medically Unt Patients
and in Re-irradiation
Elderly unfit patients with T1/T2 rectal

adenocarcinoma were treated with curative intent
by Sun Myint et al. by a combination modality
treatment consisting of external radiotherapy and
Papillion-style contact therapy [29]. This study

demonstrated an excellent local control rate of
93 % at 3 years. At a median follow-up of
4.6 years, the overall survival was 71 %, reflecting
the advancing age and the poor general condition
due to medical comorbidity of the cohort of
patients that were treated. The cancer-specific
survival was in fact 93 %.
For medically unfit patients with larger tumors
(T2/T4), the risk of nodal involvement makes
the combination of local radiotherapy (either
with contact X-rays or with high-dose-rate
brachytherapy) and external beam radiotherapy
necessary [30].
In elderly unfit patients, endoluminal brachytherapy in association with external radiotherapy
was studied in 41 patients (median age, 82 years)
at McGill University [16]. In this study, 4045 Gy
in 4/5 weeks followed by 30 Gy in three fractions
of brachytherapy was delivered with and without
surgery. Local control at 14 months was 76 %
with an incidence of grade 3 rectal bleeding
occurring in only seven patients and rectal stenosis occurring in only three patients.
Another interesting use of endocavitary HDR
brachytherapy has been evaluated by Chuong
et al. in patients who previously received pelvic
irradiation at a mean of 11 years prior to their
diagnosis of rectal cancer [31]. In this study, ten
patients received a total dose of 26 Gy in four
consecutive daily 6.5 Gy fractions. Among the
six patients who went to surgery in follow-up,
two had a pCR and two others a near pCR. Five
had negative surgical margins. As for tolerance,
there was no grade 3 or higher toxicity and no
patients had significant intraoperative or
postoperative complications. In this particular
population of patients, preoperative endorectal
HDR brachytherapy could be considered as an
alternative to external irradiation.
Special Clinical
Application: IORT
In cases of suspected positive margins or residual

disease, IORT is an alternative to deliver a high
dose of local radiation and reduce the risk of
local recurrences [32]. Multiple methods of
delivery of IORT are available. Either low-energy

X-rays (50 kV maximum) or 618 MeV electrons
have been used in clinical practice [6]. For lowenergy X-ray delivery, different diameters of the
spherical applicators are available and placed at
the tip of a 0.32 cm diameter tube, ranging from
1.5 to 5 cm in 0.5 cm increments. The spherical
applicator is placed into the tumor bed by the
surgeon and radiation oncologist. Normal
structures (small bowel, ureters, etc.) are shielded
by small sheets of lead covered by a sterile plastic
drape. All present operating room personnel wear
leaded aprons and stand behind a shielded screen
while IORT is delivered [33]. Additionally, IORT
may also be performed using 192I sources although
experience is limited [34].
Side Effects
Proctitis is the most frequent acute toxicity

reported with a grade 3 incidence of approximately
1 % [23]. Late toxicity is mainly represented by
bleeding which occurs in 26 % of cases (usually
grade 1 and 2) and usually resolves after 612
months. No grade 5 toxicity, perforation, or uncontrolled bleeding have been reported following
brachytherapy. In patients on anticoagulants medications, bleeding can be troublesome and argon
plasma coagulation can be useful in approximately
5 % of cases [35], although this should be used
sparingly and when all other options have been
exhausted (local steroids and vasoconstrictors).
About 10 % of patients develop rectal discomfort,
urgency, or tenesmus with steroid enemas being
potentially helpful. Fistulas and rectal stenosis
occur in less than 1 % and are generally associated
with prior surgical intervention.
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Lower Gastrointestinal
Brachytherapy: Anus
Stefania Manfrida, Luca Tagliaferri,
Rezarta Frakulli, Maria Antonietta Gambacorta,
Alessio G. Morganti, and Vincenzo Valentini
Abstract
Management of anal canal cancers has special concerns due to the functional and structural relationships of the body, especially as compared to
the remarkable radiosensitivity of tumors of this region. We present an
outline of the special role of brachytherapy and an analysis of the data to
date.
Introduction: The Need

for Brachytherapy Nowadays
Anal cancer is a rare disease and accounts for

only 2 % of digestive tract tumors and 24 % of
colon, rectal, and anal tumors [1, 2]. The annual
incidence is 1 in 100,000, is higher in women,
and is increasing [3, 4].
S. Manfrida, MD L. Tagliaferri, MD
M.A. Gambacorta, MD V. Valentini (*)
Gemelli ART (Advanced Radiation Therapy),
Catholic University of the Sacred Heart,
Agostino Gemelli Polyclinic, Rome, Italy
R. Frakulli, MD A.G. Morganti, MD
Radiation Oncology Center, Experimental,
Diagnostic and Specialty Medicine-DIMES,
SantOrsola-Malpighi Hospital, University of
Bologna, Bologna, Italy
1.1
Anatomy and Histology
The anal region is comprised of the anal canal

and the anal margin, dividing anal cancers into
two categories. However, tumors can involve
both the anal canal and the anal margin. The anal
canal is the more proximal portion of the anal
region and extends from the anorectal junction to
the junction with perineal skin (anal verge) as
defined by the American Joint Committee on
Cancer (AJCC) [5] and the Union Internationale
Contre le Cancer (UICC) [6] (Fig. 1). The superior border of the functional anal canal, separating it from the rectum, has been defined as the
palpable upper border of the anal sphincter and
puborectalis muscles of the anorectal ring. It is
approximately 35 cm in length, and its inferior
border starts at the anal verge, the lowermost
edge of the sphincter muscles, corresponding to
the introitus of the anal orifice. Useful palpable
landmarks are the puborectal sling and the intersphincteric groove. The columnar, or cylindrical,
epithelium of the rectum extends to about 1 cm

DOI 10.1007/978-3-319-26791-3_21
353
S. Manfrida et al.
354
Fig. 1 Anatomy of the
anal region
Levator ani m.
Puborectalis m.
External sphincter
Dentate line
Anal canal
Internal sphincter
Anal margin
above the dentate line where the anal transitional

zone begins. The dentate line is defined as the
limits between the columnar epithelium and the
stratified squamous epithelium of the anal canal.
This junction is not characterized by an abrupt
histological change, but rather by a transition
zone that extends for approximately 0.61.2 cm
containing epithelial columnar, cuboidal, squamous, and transitional cell subtypes. The stratified squamous epithelium extends just below the
dentate line to the anal verge defined as the junction of the squamous epithelium of the anal canal
with its perianal skin. The pigmented skin within
a 5-cm radius around the anal verge is called the
perianal skin or anal margin and is covered by
the epidermis. Tumors of the anal margin (below
the anal verge and involving the perianal hairbearing skin) are classified with skin tumors.
Because therapy for anal tumors is determined
in large part by location, it is critical that there is
universal understanding of anatomic landmarks
in this region.
Anatomic definitions of the anal and perianal
region have been confusing and controversial.
Various definitions of the anal canal exist that are
based on particular physical/anatomic landmarks

or histologic characteristics. In some surgical
series, the anal canal is defined as the region
between the dentate line and the upper margin of
the anal sphincter based upon the pathways of
lymphatic drainage. Consequently, a tumor arising below the dentate line may be defined as a
tumor of the margin [7, 8]. Recently, AJCC and
UICC have clarified the definition of the anal
canal as the portion that extends from the anorectal ring to the anal verge.
In practice at diagnosis, the precise point of
origin is often uncertain, and the distinction
between an anal canal and anal margin tumor is
often difficult. For this reason, a classification of
three distinct regions has been suggestedi.e.,
intra-anal, perianal (visualized with gentle traction on the buttocks), and skin tumors (beyond a
5-cm radius from the anal verge) [9].
For anal cancer treatment, histological confirmation by biopsy is mandatory.
In the anal canal, the most common histologic
type (80 %) is squamous cell carcinoma. Other
malignant tumors of the epithelium included
cloacogenic, basaloid, and transitional tumors
Lower Gastrointestinal Brachytherapy: Anus
which occur with a lesser prevalence [10].

Uncommon histological presentations of anal carcinomas include adenocarcinoma, undifferentiated cancer, melanoma, neuroendocrine tumors,
and small cell carcinomas [11].
Squamous cell carcinoma of the anus is
strongly associated with human papillomavirus
(HPV) infection which represents the causative
agent in 8085 % of patients (usually from HPV
16 or HPV 18 subtypes in Europe) [12, 13] as is
its precursor lesion anal intraepithelial neoplasia
(AIN) [14].
Epidermoid carcinoma is a slow growing
tumor and usually presents as an intra-anal or
perianal mass. Lymph node involvement at
diagnosis is observed in about 30 % of cases,
while systemic spread is uncommon (58 %).
Staging of anal cancer is based upon tumor
size and local extension, regional lymph node
involvement, and the presence or absence of
distant metastases. Magnetic resonance imaging
(MRI) and endoanal ultrasound increasingly are
utilized to assess tumor depth and sphincter
involvement.
Tumors of the anal margin are generally well
differentiated and more often occur in men, in
contrast to canal tumors which are normally
poorly differentiated and more common in
women. Because of tumor location and early
diagnosis, patients with anal margin tumors tend
to have a better prognosis. Very early-stage
(T1N0M0) anal margin cancer is similar to
treatment for skin cancer by local wide excision.
More advanced diseases or lesions that involve
the anal verge are managed with combined
treatment similar to those for anal canal cancers
which will be presented later in this chapter.
1.2
Combined Treatments
External beam radiotherapy with concurrent

chemotherapy (RCT) represents the primary
standard treatment in squamous anal canal
carcinoma. The aim of treatment is to achieve
cure with locoregional control and preservation of anal function for the best possible quality of life.
355
Concomitant use of radiotherapy with

chemotherapy was introduced by Nigro et al. in
1974 [15], initially as neoadjuvant therapy
preceding radical surgical resection consisting of
abdominoperineal resection (APR), thereafter as
definitive treatment with surgery reserved for
those who failed this regimen [11, 14]. The 5-year
overall survival for patients who received nonsurgical radiochemotherapy treatments (5070 %
according to clinical stage) is equivalent to that of
patients who received surgical treatment and most
are spared the need of colostomy [16].
Six randomized controlled trials conducted in
the last three decades assessed the role of concomitant use of external beam radiochemotherapy for
patients with epidermoid anal cancer and confirmed the association of radiotherapy with concurrent 5Fu and mitomycin C (MMC) as standard
treatment providing better local control and lower
colostomy rates [1723].
RCT offers a complete response rate of
approximately 8090 % in early-stage disease,
associated with a high rate of local control and
sphincter preservation with locoregional failures
of 15 %. However, especially for more advanced
patients treated with standard schedules, there is
still a 3040 % rate of locoregional recurrence. In
an effort to reduce locoregional recurrence and
the colostomy rate coupled with the observation
of high level of overall grade 3 and 4 acute
toxicity during radiochemotherapy in about 1/3
of the overall treated population (skin,
hematological, and gastrointestinal) [18, 20],
three randomized trials explored different
chemotherapeutic agents and schedules (cisplatin
instead of mitomycin C induction or maintenance
chemotherapy) [4, 21].
Data from these trials and a recent systematic
review [24, 25] continue to support the paradigm
of external beam radiotherapy with concurrent
5Fu and MMC developed over 30 years ago as
the standard of care for lower colostomy and
local failure rates with less acute toxicity.
Disappointingly, the 5-year survival has
changed little in the last two decades. In the
United States, the overall 5-year survival rate in a
patient cohort treated from 1994 to 2000 was
60 % for men and 78 % for women [4].
S. Manfrida et al.
356
Radiotherapy techniques, total dose, fraction,

planned interruption, and boost dose vary in the
randomized clinical trials, and the optimal
radiotherapy approach in combination with
concurrent chemotherapy has not been directly
explored in randomized trials.
From evidence of randomized trials and systematic reviews, international guidelines have
been formulated that suggest doses of at least
4550 Gy without a treatment gap are recommended for T12 N0 tumors [26, 27]. Higher
doses may be required for more advanced lesions,
particularly if a planned treatment gap is used.
The importance of delivering a total dose of 55
59 Gy to the tumor bed to patients with stage II/III
anal canal carcinoma as supported by retrospective studies showed better local control rates at
these dose levels even if significantly associated
with acute and late toxicity [19, 28, 29].
Uninterrupted treatment (avoiding a gap) is
considered radiobiologically to be the most effective treatment. Shorter overall treatment time
(OTT) is associated with improved outcome [30],
while prolonged OTT over 60 days showed a detrimental impact [20, 31], even for total doses
over 54Gy [29]. Therefore, in order to optimize
local control rates, individualized treatment
breaks as necessary due to acute adverse effects
may be preferred over planned treatment interruptions [33].
The introduction of 3D conformal radiotherapy-based treatments allows practitioners to identify normal as well as target soft tissue structures
on axial CT images, which has led to improved
treatment accuracy during delivery. Moreover, the
evolution of conformal treatment strategies such
as intensity-modulated radiotherapy (IMRT)
while sparing organs at risk may result in a reduction of acute and long-term toxicity in normal tissue and may allow full or even escalated doses to
be achieved within a shorter overall treatment
time [16, 32, 34]. The potential clinical benefits of
the dosimetric advantages of these techniques in
the treatment of anal canal cancer patients are
under prospective evaluation.
Boost doses to the primary tumor have usually ranged from 9 to 20 Gy, with higher doses
applied for observed poor clinical response.
International guidelines support the utility of a

boost after RCT [26, 27].
Brachytherapy
Brachytherapy (BT) has an important role in the

local dose escalation for the treatment of anal
cancer because of the physical and biological
advantages which offer a highly conformal
treatment (steep dose falloff around the source)
which is able to deliver a high dose to the primary
tumor, sparing surrounding normal tissues such
as the contralateral mucosa and sphincter.
Nevertheless, its role has not been evaluated
extensively, and at the moment there is no clear
evidence in the literature to guide the choice of
brachytherapy boost versus external beam boost
after initial external beam radiotherapy (EBRT)
for anal cancer [35].
The most frequently applied BT methods are
low-dose rate (LDR), pulsed dose rate (PDR), or
high-dose rate (HDR). These methods are
characterized by the different dose rates delivered
by the radiation sources (LDR/PDR, 0.51 Gy/h;
HDR, >12 Gy/h). The isotope iridium-192
(Ir192) is commonly used for remote afterloading
procedures.
2.1
Indications
The Groupe Europen de CuriethrapieEuropean Society for Radiotherapy and

Oncology (GEC-ESTRO) guidelines suggest
interstitial brachytherapy for delivering the
boost to the tumor bed after 45 Gy (conventional EBRT or chemoradiation) for T1T2 and
selected small T3 anal tumors responding to
external beam radiotherapy [36]..In patients
with anal canal cancer, a brachytherapy boost
after radiotherapy or chemoradiotherapy leads
to high local control rates with acceptable acute
and late toxicity. Brachytherapy alone is effective in controlling most small lesions, but
causes painful reactions in half of the patients
and late necrosis in 1015 %, and is therefore
contraindicated [37, 38].
In order to preserve the sphincter function,

there are some limitations for the use of BT in
anal cancer. Implantation of more than the half of
the circumference and a longitudinal length of
more than 5 cm should be avoided. As well, the
thickness of the tumor usually should not generally extend to more than 1.0 cm. In daily clinical
practice, patients who may benefit from BT have
localized tumors and are generally good responders to radiochemotherapy even in case of a locally
advanced clinical presentation. A more aggressive approach, which could also integrate surgery, should be considered for poorly responding
patients.
Clinical response assessment after RCT is a
crucial aspect in the indication of a brachytherapy boost. A time gap between RCT and BT
allows recovery of acute normal tissue toxicity
and regression of tumor volume; however, the
exact time for response evaluation and boost
delivery vary among the randomized trials. In
this context, important prognostic issues for local
control are the time gap between EBRT and BT
boost and OTT, with a negative impact on local
control when the time gap between EBRT and
boost is >37.5 days [32, 39]. In addition, boost
radiotherapy after a treatment interruption of 6
weeks could result in increased late adverse
effects instead of local control [40].
Regarding the impact of the OTT, data from
the CORS-03 trial showed the negative influence
on local control for OTT >80 days without influence by the boost technique. But if the OTT is
shortened to <80 days, local control is increased
significantly using the BT boost instead of an
EBRT boost [41].
In summary, a complete response after RCT,
even for a locally advanced presentation, should
be managed with a lower brachytherapy dose
thereby reducing the need for colostomy and limiting irradiated normal tissue volume, thereby
decreasing late toxicity as documented in Peiffert
and Lestrade papers [42, 43]. Incomplete tumor
response after RCT with lesions that require large
volume and higher dose cause a more severe toxicity without a real gain in terms of local control;
therefore, these situations represent a contraindication to the use of interstitial BT.
357
2.2
Anal Canal Brachytherapy

Techniques
In the past, the positioning of brachytherapy needles

was performed by assessing the tumor extent and target volume using clinical findings and not with imaging; moreover, the treatment was primarily done with
linear sources. Image-guided brachytherapy (IGBT)
and intensity-modulated brachytherapy (IMBT) due
to 3D compatible applicators allow a sectional imagebased approach with a better assessment of gross
tumor volume (GTV) and clinical target volume
(CTV) compared to traditional approaches.
Nowadays, it is strongly recommended to perform
anal brachytherapy with 3D imaging support and with
a delivery system that incorporates stepping source
technology (IMBT). Also, the European Society for
Medical Oncology-European Society of Surgical
Oncology-European Society of Radiotherapy and
Oncology (ESMO-ESSO-ESTRO) anal cancer clinical practice guidelines (2014) state that double-plane
or volume implants may be related to a risk of late
necrosis and radiation proctitis; hence, they underline
the advantage in the use of computerized 3D imagebased treatment planning which allows optimal dose
distribution [44].
2.3
Pretreatment Evaluation
and Patient Preparation
Before the brachytherapy procedure, it is necessary

to evaluate the patient to rule out BT and anesthesia
contraindications. BT contraindications are length
of the tumor greater than 5 cm, infiltration thickness exceeding 1.0-cm depth, infiltration of the
external sphincter, tumor involving more than half
the circumference of the anal canal, primary tumor
with excessive invasion of the skin, and rectovaginal fistula. Regarding anesthesia, many centers use
a general anesthesia, while others prefer a spinal
anesthesia because it is safer and causes less systemic effects. Based on clinical findings, imaging is
also necessary to define the BT technique as in
some selected cases, it is possible to use intracavitary brachytherapy. It is mandatory in cases being
considered for intracavitary BT to an accurate prediction of possible dose distribution as the contra-
S. Manfrida et al.
358
lateral mucosa could receive a much higher and

injurious dose. In such cases, it is preferable to perform an interstitial implant. The preparation of the
patient depends on the type of brachytherapy (HDR
or LDR/PDR). For HDR implantation, an enema is
recommended the evening before and in the early
morning of the day of the procedure, a light dinner
is suggested. For an LDR/PDR procedure, it is
preferable to prescribe laxatives and fast the day
before the procedure. The bowel should be kept
quiescent thereafter. Before bringing the patient to
the theater, preparation of the perianal area with
shaving and antiseptic cleansing as well as placing
a bladder catheter are required.
2.4
Template Needle Implant

Procedure
provided with a central cylinder which is inserted

into the anus to stabilize the system and to keep
straight the anus and the rectum in order to avoid
piercing of the mucosa. Often for performing a
US-guided brachytherapy, the cylinder is hollow
inside and made of US translucent material. For
RM-guided BT, the template must be MRI compatible. In general, the needles are made of stainless steel; however, for MRI-guided BT, they must
be plastic or titanium for compatibility.
2.5
CTV Denition
Using brachytherapy as a boost, the CTV is

defined by transrectal exploration and imaging
exams after EBRT CT. The most widely used
After anesthesia, the patient is placed in the lithotomy position. The template is positioned and
secured to the skin with sutures. The template
allows transcutaneous implantation of needles
through holes placed at regular, equidistant, and
parallel geometric positions which are well defined
dosimetrically. Templates are either available
commercially or can be fashioned in-house. The
needles are positioned under real-time imaging
(US or MRI) or according to the indications of the
pretreatment plan. When performing a US-guided
brachytherapy (Figs. 2, 3, and 4), it is necessary to
have a template with a central hole to insert the
probe of US devices. Generally, the template is
Fig. 3 Ultrasonographic image of needle insertion
Fig. 2 In-house-made template for US-guided BT in use

at the Catholic University of Rome
Fig. 4 Needle insertion under ultrasound guidance
imaging method for exact guidance of interstitial

radiotherapy in anal cancer brachytherapy is
endoanal ultrasound (EAUS) [35] due to excellent target delineation and easiness of application. The EAUS-guided interstitial HDR
brachytherapy for anal cancer was introduced in
the 1990s and is the first choice in anal canal BT
for implant guidance. Doniec [45] in his pilot
study demonstrated that EAUS-guided BT for
anal cancer is safe in terms of side effects compared to conventional brachytherapy. In addition,
the use of this technology in combination with
brachytherapy improves local tumor control and
minimizes morbidity in patients with anal carcinoma. Moreover, under ultrasound control the
needles are implanted directly into the tumor or
tumor bed and real-time treatment planning is
possible [46]. Regarding other image-guided
technique, Christensen et al. in 2008 and Niehoff
in 2014 reported the possible use of MRI in the
practice of interstitial BT of the anus. The stated
limitations were the possibility of having an open
MRI machine and the necessity of MRIcompatible templates and needles [42, 47]. A
pre-procedure exam is useful to define the target
because after the implantation the needles may
create artifact. Additionally, MRI is useful if the
simulation is performed with only the treatment
planning computer (TC) where the lesion is difficult to detect. In these cases, fusion software
can be very useful.
2.6
Dosimetry
Following needle implantation, the patient

undergoes imaging. Three-dimensional imaging
is strongly recommended. It can be 3D US, CT,
or MRI. The dose planning process should follow the general rules of the Paris system, with
additional manual volume optimization (Fig. 5).
The CTV and dose to organs at risk (OARs)
should be documented using a dose-volume histogram (DVH). The OARs are the rectum, bladder, and the uninvolved anus. For planning
evaluation, it is appropriate to calculate the volume coverage with 200 % of prescribed dose
(V200), 150 % (V150), 100 % (V100), and 85 %
(V85). Other quality indicators for the treatment
359
Fig. 5 Example of a treatment plan on TC with dose

optimization
plan are D90, D100 (dose delivered to 90 % and

100 % of the CTV, respectively), and the DHI
(dose homogeneity index, [V100V150]/V100).
All parameters have to be reported in the BT
metrics [48].
The dose nonuniformity ratio (DNR) is calculated as D150/D100 and should not generally
exceed 0.32. However, in the analysis published
in 2014 by Kapoor et al. [49], the DHI was 0.83
and the DNR was 0.37. In another study published in the same year by Falk et al. [48], these
parameters were 0.58 and 0.38, respectively.
Major et al. considered that the larger target volume involves longer active length and the
increase of active length improves the dose uniformity and the optimal dosimetry. DNR and
DHI distant from recommended indications
could be justified by a low treatment volume
because the implant geometry is applicator
dependent [50, 51].
2.7
Anal Cancer Brachytherapy:

Clinical Results
In this section, we reviewed the literature on BT

boost in anal cancer. In Table 1, a summary of
clinical results of multiple studies is reported.
In 1994 Wagner et al. published the results of
96 patients treated with an interstitial 192Ir implant
162
84
99
209
19811998
20002004
20032010
20002005
19922009
Weber et al.
(2001) [32]
Hannoun-Levi
et al. (2011) [54]
Oblak et al.
(2012) [39]
Moureau Zabotto
et al. (2013) [41]
Lestrade et al.
(2014) [43]
CDDP + 5Fu
or
5Fu + MMC
5Fu + CDDP
5Fu + MMC
5Fu + CDDP
5Fu + MMC
CT
5Fu + CDDP
Median, 32
Median, 31
Mean, 27
Median, 36
Median, 37.5
BT, 209 pts
EBRT, 49
pts; BT, 50
pts
EBRT, 33
pts; BT, 49
pts
EBRT, 41
pts; BT, 49
pts
EBRT, 76
pts; BT, 86
pts
Interval between
EBRT and boost
(days)
Boost
Median, 56
BT, 85 pts
LDR or PDR median

dose, 18 (range
1031.7)
LDR median does,

17.2 (range 1025)
PDR BED, 3040
LDR median dose,

17.4 (range 1025)
LDR median dose,

18
BT technique/
dose(Gy)
LDR median dose,
19.1 (range 1428)
72.8
71.5
43
62
76.2
FU (months)
64
OS, 78 %;
CRLR, 21 %;
CFS (BT),
71 %; CFS
(EBRT), 56 %
LRC, 71 %;
OS, 67 %;
CFS, 85 %;
DFS, 68 %
CRLR, 21 %;
CRDR, 19 %;
CFS, 63 %;
OS, 74.4 %
OS, 80.9 %;
LC, 78.6 %;
CSS, 85.7 %;
CFS, 79.4 %
OS, 76.7 %;
LRC, 72.5 %
Outcomes (5
years)
OS, 84 %;
CSS, 90 %;
CFS, 71 %
BT brachytherapy, CDDP cisplatin, CT chemotherapy, CRLR cumulative rate of local recurrence, CFS colostomy-free survival, CSS cancer-specific survival, CRDR cumulative
rate of distant recurrence, (including nodal), DFS disease-free survival, 5Fu 5-fluorouracil, FU follow-up, EBRT external beam radiotherapy, LDR low-dose rate, LRC locoregional control, LC local control, MMC mitomycin C, OS overall survival, PDR pulsed dose rate
Median, 45
Median, 45.1
45
Median, 45.1
No. of pts EBRT dose (Gy)

95
Papillion
technique (30
Gy direct
perineal
field + 18 Gy
sacral field or
3-fields, 39 Gy)
90
40
Period
19821993
Author (year)
Gerard et al.
(1998) [53]
Table 1 Summary of studies using interstitial brachytherapy boost in anal cancer
360
S. Manfrida et al.
boost. A complete response was recorded 2

months after BT in 104/108 patients (96 %).
Five-year overall survival (OS) and specific
survival were 64 % 6 and 72 % 8, respectively.
Sphincter preservation was achieved in 85 % of
patients [52].
Gerard et al. reported a retrospective analysis
of 95 patients treated with external beam radiotherapy (EBRT) followed by BT. During EBRT,
all patients received one course of 5Fu and cisplatin. The OS at 5 and 8 years was 84 % and
77 %, respectively, and the cancer-specific
survival was 90 % and 86 %, respectively. The
colostomy-free survival (CFS) was 71 and 67 %,
respectively, in the same time frame [53].
Weber and colleagues analyzed the impact of
gap duration on locoregional control in 90
patients treated with 40 Gy EBRT + chemotherapy followed by 20 Gy BT (49 patients) or EBRT
(41 patients) [32]. The median gap was 37.5 days.
In both univariate and multivariate analyses, a
prolonged gap (>37.5 days) was reported as an
independent unfavorable prognostic factor for
locoregional control (p, 0.02). Also age < 65
years was a significant independent factor (p,
0.01). Based on multivariate analysis, the authors
stratified the patients in four prognostic groups:
Group 1 (favorable prognosis): older patients
with a shorter gap (<37.5 days)
Groups 23 (intermediate prognosis): older
patients with a prolonged gap and younger
patients with a short gap
Group 4 (unfavorable): young patients and
prolonged gap
In older patients, 5-year actuarial LRC was
92.3 % and 75.0 % for shorter and longer gaps,
respectively. In younger patients, the
corresponding values were 73.7 % and 50.0 %,
respectively. Locoregional control (LRC) for all
patients was 72.5 %.
Widder and coworkers retrospectively
analyzed factors influencing local control and
survival in patients treated with chemoradiation
for anal cancer [31]. In this study, 18 % (23/129)
of patients received a BT boost. Median overall
361
treatment time (OTT) was 63 days for the EBRT

boost cohort and 55 days for BT boost cohort. In
stage T12 tumors, a shorter OTT favored local
control (p, 0.015). For T3T4, higher total radiation dose and female gender were associated with
improved local control (p, 0.021). Five-year OS
and LRC were 57 % and 87 %, respectively.
Oblak and colleagues published the results of
84 patients treated with 45 Gy EBRT with concurrent chemotherapy (5-fluorouracil and mitomycin C), followed by BT or EBRT boost [39].
At 6 and 18 weeks after treatment, complete
response was recorded in 65.5 % and 79.8 %,
respectively. At multivariate analysis, complete
clinical response was identified as an independent
prognostic factor for locoregional control (LRC),
disease-free survival (DFS), and disease-specific
survival (DSS). The 5-year LRC, DFS, DSS, OS,
and CFS rates were 71 %, 68 %, 81 %, 67 %, and
85 %, respectively. Skin toxicity was the most
frequent G3G4 acute toxicity, occurring in
58.2 % of patients. The most frequent late G3
G4 toxicities were incontinence and anal stenosis, occurring in 18 % of patients. In the BT boost
group, less late side effects were observed compared to the EBRT boost.
A multicenter retrospective French study
(CORS-03) compared EBRT versus BT boost
after 45 Gy EBRT [54]. In this study, 86 patients
received 17.4 Gy (range 1025 Gy) low-doserate BT boost and 76 patients received a mean
dose of 18.3 Gy (range 825 Gy) EBRT boost,
respectively. The mean OTT was 82 days (range,
45143) for the EBRT group and 67 days (range,
37128) for the BT group. Five-year cumulative
rate of local recurrence (CRLR) was 21 %. At
multivariate analysis, BT boost was the only
prognostic factor associated with lower CRLR. In
the subgroup of patients with OTT <80 days,
5-year CRLR was significantly reduced by delivery of a BT boost (BT 9 % versus EBRT 28 %)
(p = 0.03)). In a multivariate analysis of a subgroup of 99 patients with lymph node involvement, BT boost in N1 patients was the unique
prognostic factor for CRLR (4 % for BT versus
31 % for EBRT; p, 0.042). Five-year CRLR and
OS were 21.0 % and 74.4 %, respectively.
S. Manfrida et al.
362
Recently, Lestrade and colleagues reported a

retrospective analysis of 209 patients treated
with 45 Gy EBRT + chemotherapy followed by
18 Gy BT boost (low dose rate or pulsed dose
rate) [43]. Severe acute and late G3G4 toxicity
occurred in 11.2 % and 6.3 % of patients,
respectively. The univariate analysis showed
that pelvic treatment volume (p = 0.046) and
total dose (p = 0.02) were associated with a risk
of severe acute and late toxicities, respectively.
Local control (LC) rates at 5 and 10 years were
78.6 % and 73.9 %, respectively. Overall, BT
showed an acceptable toxicity profile and high
local control rates.
2.8
Future Perspectives
The combination of RCT and BT allows higher

doses to be delivered to the tumor. Improvements
in local control and reductions in toxicity therefore become possible by integration of more
advanced external beam delivery techniques
(such as IMRT) with new BT techniques, such as
high-dose-rate BT (HDR-BT) with the aim to
reduce local failure and the risk of late radiation
proctitis [55].
The evolution of the modern image-based 3D
treatment planning for BT and the possibility of
intensity modulation in brachytherapy (IMBT)
may offer the most conformal treatment available
to boost small volumes after radiochemotherapy
for a higher possibility of success and better tolerance. The introduction of transrectal ultrasound
(TRUS) and magnetic resonance imaging (MRI)
make possible image-based implants, resulting in
high precision therapy. The use of image-guided
brachytherapy (IGBT) allows a better target volume definition and is recommended to guide the
implantation procedure [56]. Imaging allows for
control of the dose distribution and ensures that
the whole of the tumor is covered by the reference isodose.
Prospective studies are needed to assess better
the BT role and its clinical meaning in the multidisciplinary and tailored approach to this disease
in the era of image guided radiotherapy (IGRT).
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Brachytherapy of the Skin: Cancers

and Other Diseases
James Fontanesi, Brian Kopitzki, and Eric Van
Limbergen
Abstract
SkinWe tan it, we burn it, we pierce it, we ink it, and we moisturize it.
When it is wet, we try to dry it, we shave it, and we inject it, and all these
things are done in an effort to enhance the appearance of it. Brachytherapy
has been used in the management of skin cancer since the first days of
therapeutic intervention shortly after the discovery of radium. We present
this chapter as a complete reference not only in the standard of care, but to
highlight novel applications of the science.
Introduction
Skin is the largest organ of the body, and for most

individuals, it encompasses approximately 20
square feet of protective surface which we often
take for granted. Our skin protects us from various infections and from the elements by helping
to maintain and regulate body temperature. It
permits tactile sensation and most importantly
has a great capacity for healing. However, there
are situations in which the damage that occurs to
J. Fontanesi, MD (*)
Radiation Oncology, Botsford Cancer Center,
Oakland University/William Beaumont School of
Medicine, Farmington Hills, MI, USA
the skin results in conditions which require medical attention. In some of these conditions, the utilization of radiation has been very effective in
helping to alleviate and control both malignant
and benign problems.
In this chapter we will discuss the use of
brachytherapy in the treatment of various skin
conditions. We will discuss when to consider
brachytherapy, review published guidelines and
clinical results, and discuss various technical
aspects that make brachytherapy for skin applications so unique.
Anatomy
B. Kopitzki, DO
Department of Dermatology, Michigan State College
of Osteopathic Medicine, East Lansing, MI, USA
The skin is comprised of three individual layers

(Fig. 1); they are the following:
E. Van Limbergen, MD, PhD

Department of Radiotherapy, University of
Gasthuisberg, Leuven, Belgium
1. The epidermis, which is the outermost layer.

It provides a waterproof barrier and is

DOI 10.1007/978-3-319-26791-3_22
365
J. Fontanesi et al.
366
Fig. 1 Skin anatomy
Epidermis
Dermis
Hair Follicle
Hypodermis
Sweat Gland
Fat
Blood
Vessels
Connective Tissue
responsible for creating our skin tone. The

epidermis is probably the single most abused
organ in the human body on a day-to-day
basis.
2. The dermis, which lies below the epidermis. It
contains connective tissue, hair follicles, and
sweat glands.
3. The subcutaneous tissue, also known as the
hypodermis, is made up of fat and connective
tissues. It also helps structurally facilitate vascular supply.
The skins color is created by special cells
called melanocytes which are located in basal
layer of the epidermis. These are critically
important as they help protect us from sun
damage by the production of melanin which is
able to absorb ultraviolet rays. It is known that
prolonged exposures to the sun will increase
the melanocytic production and in many cases
help with the darkening of the skin as a protective mechanism. The skin is essential in the
activation of vitamin D which is critical to the
integrity of the osseous system. It is also
known that the skin is not uniform in its thickness. The thinnest areas of the skin in the body
are located around the eyelids, while the thickest resides on the palms and the soles of the
feet [1].
2.1
Skin Layer Activities
2.1.1
Epidermis
As noted, the epidermis is the outermost layer of

the skin. It is responsible for fluid management
and prevention of pathogen introduction and
plays a major role in body temperature regulation. It is composed of stratified squamous epithelium, and keratinocytes make up the majority
of cells in this layer compromising 95 % of the
epidermis, while other selected cells such as the
Merkel cells, melanocytes, and Langerhans cells
are also present. Beginning with the outermost
portion of the epidermis, there are five layers:
Stratum corneum
Stratum lucidum (which is located only in the
palms and soles)
Stratum granulosum
Stratum spinosum
Stratum germinativum (which is also known as
the stratum basale)
The keratinocytes in the stratum germinativum layer proliferate through mitosis, and these
daughter cells move up the various strata toward
the surface of the skin changing their shape and
composition as they undergo multiple stages of
cell differentiation until they eventually become
Brachytherapy of the Skin: Cancers and Other Diseases
367
anucleated. As this process occurs, these cells

produce keratin proteins and lipids which help in
the formation of an extracellular matrix that provides mechanical strength to the skin. Once the
cells reach the outer layer, they are eventually
shed from the surface in a process which is
known as desquamation. The transitional zone
between the epidermis and the dermis is defined
by a thin sheet of fibers which is known as the
basement membrane. This basement membrane controls the migration of the cells and
molecules between these two layers and also
contains a variety of cytokines and growth factors which are used as a reserve for controlled
release during physiological remodeling or
repair [2].
2.1.3 Hypodermis
The purpose of the hypodermis is to attach the
skin to the underlying bone, muscle, and
connective tissues as well as maintaining the
supply of blood vessels and nerves. It consists of
connective tissue and elastin with the main cell
types being fibroblasts, macrophages, and
adipocytes. It should be noted that the hypodermis
contains 50 % of the body fat. This fat serves as
padding and insulation for the body [4].
Despite the importance that the skin plays in
our overall health, insults occur not only on a
natural basis but also deliberately and sometimes
on a daily basis. These insults often result in
conditions which require intervention for both
malignant and benign processes.
In this chapter we will discuss these various
conditions and how brachytherapy has been
utilized in their management and treatment. We
will cover squamous cell carcinoma, basal cell
carcinoma, and melanoma as the main oncologic
foci. In addition, we will discuss benign processes
such as keloid/heterotopic scar formation,
hidradenitis suppurativa, and other benign
conditions which have been treated with
brachytherapy techniques.
2.1.2
Dermis
This is the second layer of skin that consists of

connective tissues and helps provide tensile
strength and elasticity through an extracellular
matrix composed of collagen microfibrils and
elastic fibers embedded in proteoglycans. This
layer has also many of the nerve endings that
help to provide tactile, thermal, and pain sensation. It also contains hair follicles, sweat
glands, sebaceous glands, apocrine glands, and
lymphatic and vascular structures. The vascular structures in this layer are important as they
help with providing nutrients and also in waste
removal from the epidermis. The dermis is
often considered to be divided into two regions,
and the region closer to the epidermis is known
as the papillary region. The deeper area,
which is thicker, is known as the reticular
region.
The papillary region is composed of connective tissue and provides the dermis with the
ability to interact with the epidermis strengthening the connection between these two layers
of skin.
The reticular region is composed mostly of
dense irregular connective tissues with a dense
concentration of collagenous elastic and reticular
fibers. It is these fibers that give the dermis
strength, extensibility, and elasticity. Within this
region are blood vessels, sweat and sebaceous
glands, and the roots of hair and nails [3].
Skin Cancer
A recent review of 75 studies conducted over the

past half century looked at geographic variations
in trends worldwide in non-melanomic skin
cancers, and not surprisingly, the highest rates
occurred in areas in which there was prevalent
sun exposure [5]. Skin cancers now represent the
number one cancer diagnosis, not only in the
United States, but worldwide. As the medium age
of the population increases and with ever
increasing exposure to various environmental
factors that allow for the development of these
cancers, the numbers of new skin cancers will
continue to grow in the future [6].
While there are traditionally identified causative effects related to the development of various malignancies of the skin that do not need to
be rediscussed in this chapter, there are other less
reported causative events which do need to be
368
noted as often skin cancers related to these factors have a perceived more virulent course.
These factors include previous exposure to ionizing radiation [7, 8], patients who are immunocompromised secondary to infectious diseases
Ebstein Barr Virus (EBV) or related to immunosuppression in transplant patients [911],
patients who develop malignancy in scar tissue
or chronic inflamed tissue [12], and patients with
a known genetic predisposition such as those
with xeroderma pigmentosum or those with
nevoid basal cell carcinoma (Gorlin syndrome)
[13].
The two most diagnosed skin cancers are
basal cell carcinoma, which compromises
approximately 65 % of all skin malignancy, and
squamous cell carcinoma, which accounts for
approximately 30 % [5].
Basal cell carcinomas are lesions that arise
from the basal cells of the skin and appear with
various presentations. Clinically, five different
subtypes are discerned: superficial spreading,
nodular, morphea-like, pigmented, and ulcus
rodens that invades and destroys the local
anatomy. If left alone, they can grow to large
sizes and become quite disfiguring. However,
they rarely metastasize beyond the original site
[14]. It is estimated that there are over 2.8 million
cases of basal cell carcinoma diagnosed in the
United States each year (Fig. 2). Often patients
have multiple sites of involvement at diagnosis.
Squamous cell carcinomas, as the name
implies, involve abnormal growth of squamous
Fig. 2 Solitary lesion/basal cell carcinoma
J. Fontanesi et al.
cells which compromise most of the epidermis.

They too can present in different ways in terms of
their appearance (superficial spreading, exophytic, and ulcerating). While not as prevalent as
basal cell carcinomas, it is estimated that over
700,000 squamous carcinomas are diagnosed in
the United States annually [15].
What differentiates squamous cell carcinoma
clinically from basal cell carcinoma is its higher
propensity for the development of lymph node
and, eventually, distant metastasis. It is estimated
that 2500 individuals yearly will die of squamous
cell carcinoma of the skin. Another differentiating factor is that squamous cell carcinomas not
only appear in areas exposed to the sun but also
can occur in all areas of the body that have squamous cells including the mucus membranes, head
and neck, and genital regions (Figs. 3 and 4).
There are certain precancerous growths that
can be associated with a development of squamous cell carcinomas. These include actinic keratosis, in which up to 10 %, if left untreated, will
advance to squamous cell carcinomas [16]
(Fig. 5).
Actinic cheilitis, which most often occurs in
the lower lip resulting in a dry, cracked, scaly
appearance, is also associated with the development of squamous cell carcinomas [17] (Fig. 6).
Bowens disease is an entity which is generally considered to be a noninvasive form of
Fig. 3 Supraorbital squamous cell cancer. Figure 3:

Squamous cell cancer of the supraorbital scalp
369
Fig. 4 Squamous cell cancer of mucosal lip

Fig. 7 Bowens disease
Fig. 5 Actinic keratosis of the scalp
reported that there is even a form of Bowens disease associated with the human papillomavirus
(HPV) [18] (Fig. 7).
While the mainstay of treatment for these
lesions remains surgical intervention, there are
often cases in which other therapies, including
the use of radiotherapy, are required. Radiation
therapy is required if the margins are positive
after surgical intervention, in patients that are not
considered surgical candidates, or in patients
who have developed lesions in areas that would
result in functional and/or cosmetically displeasing deformities. The latter are usually noted in
areas around the eyelid, the nasal labial fold, and
the ear. It is these cases in which the use of radiotherapy has been shown to be an effective treatment. We will confine the majority of our
comments in this chapter to the basal cell and
squamous cell carcinomas.
Fig. 6 Actinic cheilitis
squamous cell carcinoma, most often presenting

as a reddish-brown scaly area that oftentimes is
confused for psoriasis or eczema. It has also been
Radiation Therapy Overview
When a patient is referred for radiation therapy

for basal or squamous cell carcinoma of the skin,
external beam irradiation is most often utilized. It
has a strong historical record of long-term local
control. Oftentimes because of the ease of
application, patients receive only external beam
J. Fontanesi et al.
370
irradiation either for unresected lesions or for

lesions that have had positive margins.
In recent publications, the clinical/pathological
finding of perineural involvement (PNI) has been
shown to have a significant influence on local
control and potential for metastasis, particularly
in squamous cell carcinoma [19, 20]. Thus, this
finding must be taken into account especially in
sites with adjacent lymphatic drainage, in which
case external beam techniques may provide
improved dose coverage. Various dose fractionation schemes have been utilized, and the longterm success rates have been quite high. Results
of various external beam series for basal cell carcinoma (BCC) and squamous cell carcinoma
(SCC) are noted in Table 1.
There is, however, also a rich tradition for the use
of brachytherapy for various skin malignancies.
Whether using interstitial techniques or surface
mold techniques or more recently with the introduction of electronic brachytherapy, the success rates of
brachytherapy have been equivalent with those associated with external beam irradiation (Table 2).
The choice of external beam radiotherapy versus brachytherapy often is based on patient presentation, overall condition, and comfort with the
treating radiation oncologists ability to deliver
either modality. Oftentimes brachytherapy
becomes a more suitable option because of the
ability to modulate the dose through the
brachytherapy field to various depths because of
lesional size, especially in non-resected lesions.
Besides the more traditional diagnosis in
which radiation and specifically brachytherapy
are used, there are various skin conditions, both
malignant and benign, in which brachytherapy
applications have been utilized. Malignant
melanoma, Merkel cell carcinoma, Kaposis
sarcoma,
and
cutaneous
non-Hodgkins
lymphoma malignancies, although traditionally
treated with external beam techniques, have also
enjoyed successful local results when
brachytherapy has been used. The results of
several selected reports are listed in Table 3.
The technical aspects of delivery for the
orphan tumors are similar to that utilized in
other skin sites. However, one exception should
be noted. At William Beaumont Hospital, a small
series of cutaneous NHL patients with extensive

scalp involvement were referred for treatment.
Because of the extensive skin involvement and
curvature of the skull, it was elected to treat with
a bonnet that was constructed of Aquaplast
with HDR catheters imbedded into it (Figs. 8). It
was designed to allow for margins similar that
what are used in the traditional external beam literature, but with the advantage of avoiding
unnecessary brain irradiation. We treated using a
BID schedule of 325350 cGy/fraction for eight
fractions over four treatment days while others
have utilized 4 Gy BID 8 fractions. Our intent
was to ensure that not more than 50 % of the
treatment volume received greater than 125 % of
the prescribed dose. All patients developed alopecia, mostly resolved during follow-up, with no
local recurrence at a median of 4 years.
4.1
Target Volume
The clinical target volume we recommend for

well-delineated squamous cell or basal cell carcinomas is the palpable visible tumor with a margin of 0.30.5 cm for skin cancers and 0.50.7 cm
for lip cancers. For ill-defined lesions, such as
morphea-like basal cell carcinomas, a wider margin is taken (0.71.0 cm).
4.2
Commonly Used Techniques
Several techniques are available, and all of them

can be carried out under local anesthesia (hypodermic needles, silk wires, and inner nylon tubes)
or without anesthesia (mats and molds, Leipzig,
Valencia, or electronic brachytherapy). Target
depths up to 0.3 cm, less than 3.0 cm diameter,
and flat in shape are good candidates for Leipzig
or Valencia applicators or electronic brachytherapy. Targets up to 0.5 cm depth, >3.0 cm diameter,
and/or with a curved shape can be treated with
plastic afterloading catheters spaced 1.01.5 cm
apart in a mask, mat, or mold. Thicker targets and
locations in the lip, inner canthus, or eyelid require
an interstitial 5-French plastic afterloading tube
implant, usually under general anesthesia.
1987
1991
1984
2012
1989
1996
2001
Petrovich
Wilder
Fitzpatrick
Lin
Abbatucci
Schlienger
Locke
850
531
675
222
498
115
646
N
334
Eyelid
All
All with
path PNI
Face
HN
All
Face
Site
Pinna
4455 Gy
Various based on histology/
site
60
72
Minimum 36
months
62 months BCC
42 months SCC
24
2060 Gy in 130 Fxb
BCC 55 Gy/20 Fx SCC 55

Gy/25 Fxc
3060R/3 Fx
40 months
N/A
3051 Gya
2073 Gy
F/U months
3.3
Dose
3560 Gy
For large tumors/cartilage involvement 70 Gy/2 Gy Fx

Most common dose schedule 20002250/1 Fx, 35004000/5 Fx
c
Median dose/number fractions
BED Biological equivalent dose
Year
2000
Author
Silva
Table 1 External beam irradiation for BCC/SCC
97.5
93 for 1 80 for recur
78 % 5 years SCC 91 %
5 years BCC
96 %
2 cm 99/98 5/10 years

25 cm 92/79 5/10 years
>5 cm 60/ 5/8 years
St III 95 %/5 years
St III/IV 50 %/5 years
94.7 % 3 years
LC
79.2 5 years
5.7 %
5.8 %
3%
N/A
4.4 % STN 9.6 %
3 case STN
Complications Gr III/IV
7.3 % at 5 years Risk with
lesion size, fraction size
N/A
17 cataracts
20 keratitis
10 enucleations
1 glaucoma
1 vitreous bleed
Median time to
recur 20 months
8 % LN Mets
2.6 % Tumor
PNI histologically
Others
Failure with low
BED, lesion 2 cm
N/A
[25]
[26]
[24]
[23]
[22]
[21]
[20]
Ref
[19]

371
1990
1989
2013
2013
2014
2005
2011
Crook
Mazeron
Gauden
Bhatnagor
Krengli
Rio
Ducassou
Eyelid
Allb
Facial
132c
All
All
Nasal
All
Site
Face
60
97
171
236
468
762a
N
136
LDR
LDR (R-192)
e HDR
LDR
IR-192
Rol-226
Gs-137
Sr-90
HDR
Type Tx
HRD
5170 Gy (mean 65 Gy)

5065 Gy (55 Gy)
5060 Gy (52 Gy)
Group A 6070 Gy Med = Gy
Group B 6065 Gy Mean = 60d
40 Gy
36 Gy/3 Fx at 0.30.4 cm
Dose
6080 Gy/180cGy/Fx at
0.5 cm
60 Gy at 85 % IDL
NA
72
36 months
60
10 months
66
60
24
F/U
60
IDL isodose line, e electronic

a
762/1676 treated with brachytherapy
b
Group 1, no surgery; Group 2, surgery brachytherapy
c
Group A, primary treatment; Group B, recurrent treatment
d
Group A, dose rate 65.2144 cGy/HR; MED=99.4; Group B, dose rate 74115 cGy/HR;MED=92.5
Year
2000
Author
Guix
Table 2 Brachytherapy results for BCC/SCC
87 % 0.5 years
96.7 %
91 % 80 %
100 %
98 %
LC
99 % for 1
87 % for recur
97.5 %
95 % for 1
94 % for recur
3 % Gr III
100 % Desquamation healed by 10
weeks
28.6 % Gr I
7.5 % Gr III
with dose rate >98C GY/h
71 % Gr 1
34 % Gr II
9.2 % Gr III
2%
2%
Complication
0%
[34]
[32]
[33]
[31]
[30]
[28]
[29]
Ref
[27]
372
J. Fontanesi et al.
2013
2014
2011
2011
2013
2013
2013
Scepanovic
Shi
Chaudhuri
Smithers
Garibvan
Kasper
Desimone
10 pts 23
Lesion
10 pts/152
lesions
16
6
3
1
24
# pts
1
NHL
KS
MCC
MM
MM
MM
MM
8 Gy/2 Fx at 3 mm
24 Gy/4 FX 35 Gy/6 Fx
1R-192 HDR 3036 Gy/5-6 Fx

32 Gy/8 Fx
42 Gy/7 Fx
1012 Gy 12 Fx at depth 510 MM
10 4 Gy at 3 mm 2/weeks
Perm I-125
Tumor type Dose

MM
30 Gy EBI + 18 Gy/3Fx
100 %
100 %
99 %
Y
55 % at 2
years
100 %
100 %
Local control
N
6.3
41
34
23
21
N/A
19.6
F/U
N/A
13/16 Gr I
2/16 Gr II
N/A
Gr II 20 %
1/6 Gr IV skin
N/A
Complications
N/A
Legend MM malignant melanoma, KS Kaposi sarcoma, MCC Merkel cell carcinoma, NHL non-Hodgkin's lymphoma
Year
2011
Name
Hobbs
Table 3 Other malignant skin conditions treated with brachytherapy
[41]
4/10 distant disease
[43]
[42]
[39]
[40]
2/6 from distant disease

Fibrosis/telangiectasis
All lesion < 2 cm Tx volume =

Lesion + 4 mm Leipzig
N/A
[37]
[38]
Ref
[36]
Other information
Initial good response in field but
eventually fails
Developed systemic disease
Estimated 2 years LC 83 %

373
J. Fontanesi et al.
374
Figs. 8 The bonnet technique
Most skin cancers can be treated by a singleplane implant, using parallel catheters, spaced
1.01.5 cm from each other. The treated thickness of such implants varies. Consequently the
source carriers must be implanted 0.20.5 cm
beneath the skin surface. Implants which are
more superficial may result in late visible telangiectasia along the source positions.
For curved planes, which frequently occur
in skin cancers of the face, the reference isodose projects further at the concave than the
convex surface. The arrangement of implanted
catheters in those cases must take into account
this shift in the isodose lines. Thicker lesions
may have to be treated by double-plane
implants. However, sometimes it is easier to
shave the exophytic part of the tumor with
electrocoagulation.
4.3
Afterloading Technique
4.3.1
Classic Plastic Tubes Henschke
Classic plastic tube implants (0.160.19 cm

external diameter) can be used for large lesions
of the periorbital area, the cheek, and the shoulder region. Because of the large volume that has
to be anesthetized, general anesthesia is usually
required (Figs. 9 and 10).
There are cases that are clinically challenging,
and our initial instinct may be that there is little
we can do; however, each case should be
individualized and considered. Even the most

untoward appearing tumor may sometimes be
managed by brachytherapy (Figs. 11, 12, and 13).
Dosimetry
Source reconstruction is done using 3-D images

as is target delineation GTV and CTV. For skin
tumors, usually no PTV margin is added, unless
there is an uncertainty of mold, mat, or mask
positioning. In the case of interstitial implants,
mean central dose (MCD) is determined. The
prescribed dose to the minimal target dose usually corresponds to 85 % of MCD (Paris
System). With parallel interstitial lines, application of geometrical optimization is advised to
reduce the indentation of the prescription isodose. The prescription dose after geometrical
optimization is possible on the 90 % of the mean
central dose. In an ideal implanted target, this
90 % isodose should cover the target completely.
In cases where the CTV is not covered, increasing dwell times and/or prescribing at a lower
isodose line can help to improve the dose distribution. However, as recommended by ICRU
Report 51, the prescription (minimal target dose
as well as the % to MCD) value should always
be recorded and reported.
For surface applicators and molds, the dose is
prescribed at the appropriate depth: at 0.8 cm for
Leipzig, Valencia, or electronic BT, at 0.30.5 cm
375
Fig. 9 Five-French plastic tube implant for interstitial HDR BT of a basal cell carcinoma of the right lower eyelid. Eight
fractions of 4 Gy were delivered in 4 days
Fig. 10 Five-French plastic tube interstitial implant, spaced

1.8 cm for a Merkel cell tumor of the right lower eyelid with
a wide (5 cm) safety margin toward the lymphatics of the
cheek. Eight fractions of 4 Gy were given in 4 days
Fig. 11 Large basal cell cancer 4 weeks post Mohs

surgery
J. Fontanesi et al.
376
Fig. 12 Scalp brachytherapy plan
Fig. 13 The same patient 1 year post brachytherapy alone
for molds, mats, or masks. The surface epidermal

dose constraint is approximately 10 Gy if five
fractions of 7 Gy are given [35].
Dose, Dose Rate,

and Fractionation
For LDR BT, the GEC-ESTRO prescribed dose

is 60 Gy at the 85 % reference isodose, at dose
rates between 30 and 90 cGy/h [44]. Usually a
dose rate of 4570 cGy/h is desired. Therefore,
the linear activity of iridium sources should be in
the range of 5.57.7 cGy/h linear air kerma rate
at 1 m. Depending on the linear activity and the
source spacing and length, it will take 46 days to
deliver the required dose. Although doses up to
70 Gy can be given in some large tumors, the
increase in cosmetic damage is greater than the
gain in local control expected from a dose
increase above 60 Gy [45].
Other total dose, dose rate, and fractionation
schemes have been reported in the literature.
Again much depends on whether low dose rate or
high dose rate is utilized. For those not using the

Paris System, either the Manchester System
(uneven source loading for a more homogeneous
dose which is equivalent to geometrical optimization in a stepping source PDR or HDR application) or the Patterson-Parker System (even source
loading/dose inhomogeneity) is used.
Many centers prescribe the total dose and
dose rate to the treatment volume. This usually
will be the tumor volume plus a margin.
Recommendations for hourly low dose rates generally run 3560 cGy/h which corresponds to
8401440 cGy/day. Total dose recommendations
will be based on individual patient needs but will
usually be 5060 Gy.
For cases in which HDR BT is utilized, a great
deal will depend on size and location. There have
been some reports of single fraction treatment
using between 700 and 1000 cGy for lesions less
than 1 cm that have been resected but harbor positive margins. For more traditional use, either
once daily or BID treatments can be utilized.
Again treatment prescriptions can be via the Paris
System or prescribed to the tumor volume edge
plus a margin. For single fractions/day, doses
between 5 and 12 Gy per fraction to total doses of
3660 Gy have been reported with good success
(Table 2).
For BID schedules, we recommend 300
400 cGy/fraction to similar total doses as utilized
in the single fraction per day recommendation.
One important aspect of our treatment policy is to
try and minimize dose inhomogeneity across the
tumor volume. This is often more realistic to
accomplish with HDR brachytherapy due to
source optimization. When uniform dose across
the tumor volume plus margin cannot be achieved,
we try to limit the 150 % isodose volume to less
than 25 % of the treatment volume.
Whatever prescription is used in interstitial
BT, one should always record the prescription
isodose as well as its relation to the MCD. For
surface applications, always record and report the
depth and resulting prescription isodose (MTD)
as well as the maximum surface dose at the epidermal surface.
377
Melanoma of the Eyelid
At one of the author institutions (Van Limbergen),

we have treated four eyelids in three patients with
excision and postoperative BT using eight fractions of 4 Gy HDR interstitial BT (32 Gy total)
using two parallel plastic tubes. With a follow-up
interval of 2.5 years, no patient has developed a
recurrence.
Nonmalignant Skin
Applications
8.1
Keloid
The earliest known description of keloids was

by Egyptian surgeons around 1700 BC [46].
However, it was not until 1806 that Baron
Jean-Louis Alibert identified them as a specific
entity [47].
Keloids are histologically characterized by
an abundance of an extracellular matrix of
connective tissue. The formation of this type of
scar is usually composed of a reduced amount
of type 3 (early) and an increased amount of
type 1 (late) collagen. It has been suggested that
Fig. 14 Traditional keloid of the pinna
378
Fig. 15 Hypertrophic scar
there are two possible mechanisms for the deposition of collagen in keloid lesions. The traditional theory is that the keloid results from the
localized loss of control of extracellular matrix
production of fibroblasts. A second suggested
mechanism is that the reduced degradation of
newly synthesized procollagen polypeptides may
contribute to collagen depositions in keloids [48].
Recently an analysis of 8393 differentially
expressed genes in keloids and in normal skin
has been reported [49]. In this study, 402 genes
(4.79 %) had different expression levels between
the keloid and normal skin. Two hundred and
fifty of these genes, including the transforming
growth factor (TGF)-beta 1 and the NGF (nerve
growth factor) gene, were upregulated (2.98 %),
and 152 were downregulated (1.81 %). It was
noted that there was a higher expression of
TGF-Beta 1 and NGF in keloids when compared
with normal skin. This was also identified using
reverse transcription polymerase chain reaction
analysis. Possible genetic mutations of chromosomes 2q23 and 7p11 have been suggested [52].
It is also postulated that in the posttraumatic and
chronic inflammatory phases of wound develop-
J. Fontanesi et al.
ment, these mediators may play an important

role in the keloid microenvironment and are crucial for keloid fibroblast abnormalities to
develop. This has led to suspicion that the
upregulation of the pro-inflammatory gene
expression in keloid lesions maybe responsible
for development [50].
Keloid scars should not be confused with hypertrophic scars which are raised and do not grow
beyond the boundaries of the original wound,
unlike those of keloids which may progress in a
clawlike growth pattern into the normal skin region
(Figs. 14 and 15). Keloids also have the capacity to
cause symptoms, the most common of which are
pain and itching. Complications associated with
itching include infection and ulceration of the
keloid and surrounding tissues.
Although they usually occur at the site of
some injury, keloids can also arise spontaneously.
While they are often associated with trauma,
interestingly enough, they can be quite different
in the same individual. A patient that is prone to
developing keloid scars does not necessarily
develop keloid with every insult to the skin.
Keloids are a quiet skin tissue which is more
prevalent than most realize. There is a suggestion
of racial disparity with people of Chinese and
African background potentially at increased risk
of development [51]. It has been reported that
overall between 5 and 15 % of all wounds will
develop a keloid.
Various treatments have been utilized in the management of keloids. Most commonly surgical intervention is utilized and often is combined with
injections of corticosteroids, laser treatment, retinoic
acid, silicone gel, and other local therapies in an
effort to prevent recurrences of keloid formation.
In general the use of non-radiation-based
postoperative therapies has resulted in local control rates of 4090 % (Table 4).
The use of postoperative radiation therapy,
whether using external beam techniques or
brachytherapy, has enjoyed a long history of
excellent long-term local control. Various articles
including meta-analyses have described various
doses utilized. However, what seems to be the
most important is the initiation of therapy within
24 h of surgical resection. The results of various
external beam series are presented in Table 5.
Year
2014
2009
2009
2013(Metaanalysis)
2013
2013
2013
2005
1980
2011
Author
Wang
Wu
Davison
Jin
Litrowski
Obrien
Mamalis
Soray
Janssen
Park
Surgery cryotherapy
Silicone gel
Bleomycin injection
Retinoic acid
Surgery pressure
15
28
1436
5 FU/steroid
5 FU/steroid/excision
Steroid/excision
Laser
Treatment
Surgery (22)
Steroid injection (34)
Surgery and steroid (130)
Surgery and 5 FU/steroids
97
873
919
102
166
Number
186
Table 4 Nonradiation treatment of keloids
73 % flattened
77 % favorable
89.4 %
Results
55 %
56 %
97 %
47 % cured
53 % effective
81 % lesion reduction
71 % for scar prevention
65 % for heterotrophic or
72 % for keloid
71 % major flattening
18
43
9 months
F/U
12 months
Partial ear amputation three cases hypopigmentation

Meta-analysis
Meta-analysis
26 sessions improved pain and pruritis scores
585/595-nm pulsed dye laser and 532 nm with best

response
Normal auricular shape 93 %
Others
[57]
[58]
[59]
[60]
[61]
[62]
[56]
[55]
[54]
Ref
[53]

379
Year
2007
2014
2005
2013
2011
1996
1989
2009
Author
Ogawa
Wang
Kol
Ogawa
Flickenger
Sulfane
Kovalic
Locomotor
194
113
31 (randomized
Meta-analysis
Meta-analysis
174 (earlobe)
139
#
109
XRT 1640 Gy
Surgery
Steroid surgery
Radiation
Surgery 12 Gy
Dose
10 Gy surgery 15 Gy
20 Gy
Surgery 5 Gy 4 4 Gy 5
surgery alone
Surgery post-op X RT
XRT-5 Gy
Surgery + 10 Gy
Surgery alone-29 %
Surgerypost-op XRT 71 %
Table 5 External beam irradiation results for resected keloids
89 % with 20 Gy
57 % <20 Gy
9095 % if 1619Gy/3Fx/10 days

earlobes 21.524.8/3 Fx/10 days
Other sites
8/12 (67 %)
14/16 (91.5 %)
73 %
Local control
71 % prior 2002
86 % after 2002
91 %
67 %
90 % if BED 30 Gy
96 %
36 months
6 years
12 months
18 months
F/U
18 months
2 cm, previous Tx males with

recurrate; med time to recur 12 months
20 Gy/5 Fx optimal dose
Difference noted chest wall/shoulder/

back vs face (0.009)
Meta-analysis
86 % 1 14 % recurrent, no difference
in dose
Meta-analysis
Others
Electrons
[70]
[69]
[68]
[67]
[65]
[66]
[64]
Ref
[63]
380
J. Fontanesi et al.
Year
2001
1993
2011
2008
2000
2009
2014
2010
Author
Guix
Escarmont
Kuribayashi
Fontanesi
Moglei
Vioni
DeCicco
Rio
73
49
114
892
96
36
570
#
169
SurgeryBx
Surgery1r
Sr 90Y
LDR (46) surgery
HDR (50)
LDR
SurgeryBx
(superficial)
Treatment
SurgeryBx
22 Bx
SurgeryBx
Table 6 Brachytherapy results for keloids
1000@3 mm/1Fx
20.4 Gy@5 mm
20 Gy/10 Fx
16 Gy
12 Gy
1540 Gy (20 Gy
med)@5 mm
15 Gy/3 Fx @2 mm
20 Gy/4 Fx @2 mm
830 Gy/12Fx
Dose
12 Gy/4 Fx HDR
94 %
87 %
88 %
70 %
65 %
86 %
90 %
Local control
96 % 142/147 = 96.5
18/22 = 82 %
79 %
44.5 months
42
24
61
18 months
6.9 years
F/U
84 months
0.5 cm Fx margin
91 % recur in 12 months
25 % hyperpigmentation
13 % hyperpigmentation
Median fail 12 months
Only failures were on chest wall
No grade II complications
No grade II complication
Others
[78]
[74]
[75]
[76]
[77]
[73]
[72]
Ref
[71]

381
J. Fontanesi et al.
382
While the use of external beam irradiation has

shown an excellent long-term prevention of
keloid recurrence in the postoperative setting, so
has the use of postoperative brachytherapy.
Technical aspects will be addressed later in this
chapter; however, there are certain advantages
that brachytherapy provides. Various series,
using different isotopes, techniques (HDR vs
LDR), and fraction schemes (single vs multiple),
have noted long-term keloid recurrence prevention rates ranging from 68 to 96 % (Table 6).
The advantages include reduced overall time to
complete treatment in many cases and direct visualization and placement of applicators into the
wound by the surgeon. Another consideration
when planning adjunctive treatment for keloids
is the potential for serious side effects. For
example, the use of different topical/injected
chemotherapeutic agents such as 5-fluorouracil/
bleomycin has well-defined dose-dependent side
effects. These include skin darkening, susceptibility to enhanced sun/skin reaction, itching, blistering, rash, and potential allergic reaction.
However, these side effects rarely occur with
the use of any radiation technique. Of more concern in this modality is the potential for the development of radiation-induced malignancies.
Recent reports have identified this risk [79].
Based on a Medline search of years 19012009,
Ogawa identified only five cases of malignancy
associated with postoperative radiation for keloid
prevention [80]. The article concluded that the
risk was very low when preformed with adequate doses and under conditions that provide
adequate protection of surrounding issues. For
this reason BT can be advocated as the radiation
treatment of choice since the CTV is very small
(0.5 cm around the incision) which reduces the
treated volume dramatically as compared to
external beam radiotherapy where a larger PTV
margin must be taken into account.
8.2
Technical Aspects and Dosing

in Keloid Brachytherapy
It is critically important that any patient being

considered for postoperative brachytherapy be
seen preoperatively. This will allow for evaluation of the lesion and should include measurement of lesions but also allows for
photographic images to be obtained. It is also
critical to obtain informed consent with discussion of potential side effects including the
possible development of radiation-induced
malignancies.
The surgical technique is critical in understanding the length of treatment required.
Issues related to tension created in the wound
postoperatively can play a significant role in
treatment planning and catheter placement. If
the tissue is undermined in order to be able to
provide primary closure, that undermined tissue can come under the same influences as the
primary resected keloid scar. This is perhaps
the single most important reason for failure to
obtain local control and the reason most radiation oncologists prefer to use external beam
techniques.
8.3
Technical Considerations
It is critical that the radiation oncologist be in

the operating theater at the time of catheter
placement. Generally one of the two common
techniques is employed. The first is the one
preferred by the authors: the blind end technique. In this technique, the catheters distal
end is buried approximately 1 cm beyond
the end of the wound/undermined tissue that
has to be treated. The second technique is the
through-and-through technique. In this technique, there are both entrance and exit sites. If
this technique is utilized, the distal exit site
should be 1.0 cm from the end of the wound/
undermined tissue.
One of the advantages of brachytherapy is
the single fraction treatment scheme. In our
hands we prescribe a dose of 1000 cGy calculated at 0.7 cm in all directions and treat to the
single exit skin site using the blind end technique that we prefer. Other doses such as 20 Gy
prescribed to a 0.5 cm margin with LDR BT or
two fractions of 7 Gy with a 6 h interval have
been used successfully. If using the through-
383
and-through technique, the dose should be carried to both entrance/exit sites.
8.4
Treatment Timing
In our experience, treatment can most often be

delivered in the first 24 h. Often we treat on the
day of surgery, similar to external beam techniques. When the patient presents in the postoperative setting, we perform a CT simulation with
dummy wires placed in the catheters for accurate
assessment. It is beneficial that the radiation
oncologist be present in the operating theater, in
order to identify any specific peculiarities that
may have occurred during catheter placement.
Once the planning CT is obtained, treatment
planning occurs. With single catheter use, this is
relatively straightforward. However, with multicatheter placement, we try to minimize dose
inhomogeneity. We attempt to ensure that no
more than 25 % of the treatment area receives
125 % of prescription dose. One way in which
this is accommodated is by securing the catheters
in at least two but often three areas of the wound
to ensure only minimal movement occurs, if any.
We attempt to space catheters at 1.0 cm if only
two catheters are used. If three or more are used,
which is extremely rare, we recommend 1.0 cm
from the outside edge catheters to the next
inside catheter and internal catheter spacing of
1.01.5 cm.
Fig. 16 Hidradenitis suppurativa in the axilla
Fig. 17 Above with brachytherapy applicator in place
Hidradenitis Suppurativa
Hidradenitis suppurativa is a benign skin condition that is characterized by chronic recurrent

infections often localized to axillary, groin, and
gluteal regions [81]. It has been considered a
silent disease, in that there is not much discussion about it in the public domain despite estimates of up to 4 % prevalence in certain
populations [82]. Patients often undergo many
localized surgical treatments in addition to antibiotic therapy and other therapies. There are data
on the effectiveness of external beam irradiation
for this entity, and when combined with antibiotic therapy, weight loss in obese patients, and
aggressive skin care, treatment often results in
successful long-term control [8386]. Our institution (Fontanesi) has treated over 100 sites with
external beam doses similar to those published;
however, we have found that about one third of
our patients require re-treatment at future time
points because of reactivation of these sites.
We have noted that the sites most common to
require re-treatment were those in creased areas
384
J. Fontanesi et al.
Fig. 18 Dosimetric plan showing excellent coverage
of the body such as the groins and gluteal regions,

where the use of electron beams has some uncertainty due to the sloping nature of the skin in these
areas. We have also noted on our CT treatment
planning scans that these areas often have various
depths of involvement, thus making external
beam techniques more difficult to deliver homogeneous dose coverage. Thus in a limited number
of patients, surface mold brachytherapy has
been utilized. We attempt to cover all CT-based
abnormalities with a 1 cm margin (Figs. 16, 17,
and 18) utilizing the same daily and total dose rec-
385
ommendation as with electron beam therapy

(150 cGy per day 8 fractions). This experience is
very early but the results and dosimetric improvements will continue to be evaluated.
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Conclusions
Brachytherapy has a long history of use in the

treatment of skin malignancies and non-skin
malignancies such as NHL. Excellent results
have also been reported in the prevention of
keloid recurrence postoperatively with little
second malignancy risk.
Newer brachytherapy application for nontraditional use in entities such as hidradenitis
suppurativa has been also utilized with initial
success. What is critical to all these sites/
applications is the close cooperation between
the radiation oncology and the surgical teams.
This enhanced communication leads to better
definition of tumor volume and allows, in
many cases, improved catheter placement
especially as it relates to wound closure.
Various dose rate/total dose recommendations have been published with similar
results and complication rates. It is clear
with increased hourly dose rates (LDR),
dose/fraction (HDR), and total dose delivered,
there are increased complications without
increase benefit of improved local control.
Whether the Paris, Manchester, or
Patterson-Parker System (LDR) is used or if
HDR dose optimization programs are utilized,
dose inhomogeneity is important as it can dramatically change complication rates.
In any skin site, the only limitation to the use of
brachytherapy is imagination of the physician.
Acknowledgements The authors wish to thank Susan
King for her assistance in the editing and preparation of
this chapter.
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Soft Tissue Sarcoma

Brachytherapy
James Fontanesi, Michael Mott, Jeffrey Margolis,
Gabrielle Monit, and Alain Gerbaulet
Abstract
Soft tissue sarcomas (STS) are a diffuse group of malignancies that arise
from connective tissues such as fat, muscle, nerves, and blood vessels.
They account for approximately 1 % of all adult malignancies and approximately 10 % of pediatric malignancies. They do not respect age, appearing in all age groups. Here we present brachytherapy as primary therapy or
an adjunct to management.
Introduction
Although reportedly described in ancient

Egyptian text, it appears the first published
account of soft tissue sarcomas was from
J. Fontanesi, MD (*)
Radiation Oncology, Botsford Cancer Center,
Oakland University/William Beaumont School
of Medicine, Farmington Hills, MI, USA
M. Mott, MD
Orthopedic Oncology, Henry Ford Hospital,
Detroit, MI, USA
J. Margolis, MD
Department of Oncology, Oakland University,
William Beaumont Medical School,
Rochester, MI, USA
G. Monit, MS, PA-C
Oakland Medical Group, Michigan Healthcare
Professionals, Oakland, MI, USA
A. Gerbaulet, MD
Department of Radiotherapy, Institut
Gustave-Roussy, Villejuif, France
Morgagni in 1761 in his famous textbook De

Sedibus, et Causis Morborum per Anatomen
Indagatis Libri Quinque [1].
This heterogeneous group of rare tumors
arises predominantly from the embryonic mesoderm although some have been noted to arise
from the neuroectoderm. It is also estimated that
there are approximately 50 subtypes [2].
These malignancies can arise anywhere in the
body however with the majority occurring in the
limb, limb girdle, retroperitoneal, and intraperitoneal sites, among others.
It is estimated that approximately 12,420
adults will be diagnosed with a soft tissue sarcoma in 2014. Unfortunately, approximately
4740 will die from their disease [3]. There is a
slight male predominance within the adult age
group. The most common diagnosed histology is
malignant fibrous histiocytoma (MFH), followed
by liposarcoma and leiomyosarcoma.
With STS we must not only address the primary disease site but we must have knowledge of

DOI 10.1007/978-3-319-26791-3_23
389
J. Fontanesi et al.
390
potential lymphatic and distant disease spread. It

has been noted that up to 16 % of adult STS
patients will have lymph node involvement at
diagnosis or at some time during their disease
course [4]. The histological type of STS
influences lymph node involvement with the
highest rates seen in angiosarcoma, embryonal
rhabdomyosarcoma (RMS), and epithelioid
sarcoma, while neurofibrosarcoma, liposarcoma,
and leiomyosarcoma generally have less than a
5 % risk of involvement [5, 6]. Site can also
influence lymph node involvement, with the
highest rates being identified in lesions of the
lower extremity (up to 45 %) and the lowest with
truncal presentations (115 %) [7].
Distant disease diagnosed at initial presentation
can greatly affect treatment decisions. It has been
reported that between 25 and 50 % of patients with
intermediate- or high-grade lesions measuring
more than 5 cm will have distant disease at
diagnosis or during their disease course, compared
with less than 10 % in those with low-grade lesions

less than 5 cm. Most distant spread will involve the
lungs, at least initially [8, 9].
Pediatric Soft Tissue

Sarcoma
As noted STS are not age discriminatory; it is

estimated that about 6800 new cases of STS will
be diagnosed in children less than 19 years old in
2014 [10] (Table 1).
Rhabdomyosarcoma (RMS), with its three
distinct variants, is the most common STS in
children less than 14 years old and accounts for
approximately 50 % of tumors in this age group.
RMS will account for approximately 7 % of all
childhood tumors. The remaining STS known as
non-rhabdomyosarcoma STS (NRSTS) will
account for approximately 3 % of childhood
tumors; the most common of which are fibrosar-
Table 1 Age distribution of soft tissue sarcomas (STSs) in children aged 019 years (SEER 19752008)
All soft tissue and other extraosseous sarcomas

Rhabdomyosarcomas
Fibrosarcomas, peripheral nerve, and other
fibrous neoplasms
Fibroblastic and myofibroblastic tumors
Nerve sheath tumors
Other fibromatous neoplasms
Kaposis sarcoma
Other specified soft tissue sarcomas
Ewing tumor and Askin tumor of soft tissue
pPNET of soft tissue
Extrarenal rhabdoid tumor
Liposarcomas
Fibrohistiocytic tumorsa
Leiomyosarcomas
Synovial sarcomas
Blood vessel tumors
Osseous and chondromatous neoplasms of soft
tissue
Alveolar soft parts sarcoma
Miscellaneous soft tissue sarcomas
Unspecified soft tissue sarcomas
Age
<5 years
1130
710
151
Age 59
years
810
466
64
Age 1014
years
1144
364
132
Age 1519
years
1573
350
192
% of the total
number of STS
cases <20 years
100
41
12
131
19
1
1
198
22
21
37
5
53
13
12
15
1
31
32
1
2
220
28
19
3
6
69
19
39
7
5
57
74
1
0
512
57
29
8
22
171
22
133
11
9
86
104
2
12
856
81
42
3
66
293
57
204
33
16
6.5
5
0.1
0.3
38
4
2.4
1
2
12
2.4
8.3
1.4
0.6
3
16
70
7
18
58
19
31
163
26
35
163
1
2
9
pPNET peripheral primitive neuroectodermal tumors, SEER Surveillance, Epidemiology, and End Results
a
Dermatofibrosarcoma accounts for 75 % of these cases
391
Soft Tissue Sarcoma Brachytherapy
coma, synovial sarcoma, MFH, and malignant

peripheral nerve sheath tumors.
Again one must be mindful of lymph nodes/
distant
metastases
in
pediatric
STS/
NRSTS. While unusual at diagnosis, certain nonRMS lesions have a higher propensity for lymph
node involvement; these include epithelioid and
clear cell sarcomas [11].
Prognostic factors for pediatric non-RMS
STS have been difficult to ascertain since few
institutions have large enough numbers of these
rare cases to enable evaluation. However, St.
Jude Childrens Research Hospital did publish
on a series of 121 patients. In a multivariate
analysis, positive surgical margins, intraabdominal primary site, and omission of radiation therapy predicted for increased risk or local
failure, while size 5 cm, high-grade designation, and invasiveness predicted increased distant metastases [12].
Another factor that makes pediatric STS diagnosis intriguing is the genetic predisposition of
certain patients for the development of soft tissue
sarcomas. Included in these populations are the
Li-Fraumeni syndrome, in which changes in the
p53 tumor suppressor gene can lead to an
increased risk of development of non-RMS
lesions, bone sarcomas, breast cancer, brain
tumors, and acute leukemia [13]. Patients with
neurofibromatosis type 1 have approximately
4 % chance of developing a malignant peripheral
nerve sheath tumor [14], while patients with
familial adenomatous polyposis (FAP) have an
increased risk for developing desmoid tumors
[15]. In those patients with the Werner syndrome,
an increased susceptibility to STS and premature
aging is noted [16], and in patients with germline
mutations of the retinoblastoma gene, there is an
increased risk of development of STS, especially
leiomyosarcoma [17].
Certain environmental factors also can play a
role in the development of both adult and pediatric STS. Previous therapeutic radiation exposure
results in an increased risk of development of infield non-RMS sarcoma, most commonly malignant fibrous histiocytoma (MFH) [18]. AIDS
patients with known Epstein-Barr virus infections (EBV) are at increased risk for the development of leiomyosarcoma, in addition to the
known risk of development of Kaposis sarcoma

[19]. Pediatric patients who develop non-RMS
sarcoma also have an association with chromosomal alteration. A list of some of the most commonly seen is found in Table 2.
Soft Tissue Sarcoma

Location Inuences
Often the site of origin helps in determining the

type of soft tissue sarcoma which is being investigated. Examples include MFH/fibrosarcoma
which most often develops in the legs, arms, and
trunks, while leiomyosarcoma often presents in
the uterus and digestive tract. Synovial sarcomas
are usually associated with the linings of joints
and tendon sheaths and most often present in the
legs (Table 3).
Diagnosis
Often the clinical symptoms associated with the

diagnosis of STS are nonspecific. They can often
present as a painless, slow growing, enlarging
mass that is often mistaken for a benign process.
Tumors that are readily visible are often diagnosed at an earlier time frame and are often
smaller then corresponding soft tissue sarcomas
that develop in the retroperitoneal areas because
of lack of visibility.
Workup of these lesions includes a detailed
history and physical and imaging studies.
Imaging is critical in the development of the
diagnosis of soft tissue sarcomas in that it not
only helps to delineate the extent of tumor, lymph
node involvement, and metastatic disease but
also can identify any pseudo capsule which may
help the surgeon in their quest for total exenteration at the time of surgery.
Plain radiographs are often used to help to
detect calcifications and/or rule out primary
bone malignancies such as osteogenic sarcoma.
Chest X-rays are essential in helping to establish
metastatic disease, as the lung is often the preferable site for metastatic deposits. Imaging
using computed tomography of the thorax,
abdomen, and pelvis is critical along with MRI
J. Fontanesi et al.
392
Table 2 Frequent chromosomal aberrations seen in non-rhabdomyosarcoma STS
Histology
Alveolar soft part sarcoma
Angiomatoid fibrous histiocytoma
Chromosomal aberrations
t(x;17)(p11.2;q25)
t(12;16)(q13;p11)(q33;q12), t(12;22)
(q13;q12)
t(12;22)(q13;q12), t(2;22)(q33;q12)
Clear cell sarcoma

Congenital (infantile)
Fibrosarcoma/mesoblastic nephroma
Dermatofibrosarcoma protuberans
Desmoid fibromatosis
Desmoplastic small round cell tumors
Epithelioid hemangioendothelioma
Epithelioid sarcoma
Extraskeletal myxoid chondrosarcoma
Hemangiopericytoma
t(17;22)(q22;q13)
Trisomy 8 or 20, loss of 5q21
t(11;22)(p13;q12)
t(1;3)(p36;q25) [34]
Inactivation SMARCB1
t(9;22)(q22;q12), t(9:17)(q22;q11),
t(9;15), (q22;q21), t(3;9)(q11;q22)
t(12;19)(q13;q13.3) and t(13;22)
(q22;q13.3)
t(1;2)(q23;q23), t(2;19)(q23;q13)
0, t(2;17)(q23;q23), t(2;2)(p23;q13),
t(2;11)(p23;p15) [35]
t(7;16)(q33;p11), t(11;16)(p11;p11)
Inflammatory myofibroblastic tumor
Low-grade fibromyxoid sarcoma

Malignant peripheral nerve sheath tumor
Myxoid/round cell liposarcoma
Rhabdoid tumor
Synovial sarcoma
Tenosynovial giant cell tumor
t(12;15)(p13,q25)
17q11.2, loss or rearrangement

10p, 11q, 17q, 22q
T(12;16)(q13;p11), t(12;22)(q13;q12)
Inactivation SMARCB1
t(x;18)(p11.2;q11.2)
t(1;2)(p13;q35)
Genes involved
ASPL/TFE3 [2931]
FUS/ATF1, EWSR1 [32],
EWS/ATF1
ATF1/EWS, EWSR1/
CREB1
ETV-NTRK3
COL1A1/PDGFB
CTNNB1 or APC mutations
EWS/WT1 [33]
WWTR1/CAMTA1
SMARCB1
EWSR1/NR4A3,TAR2N/
NR4A3, TCF12/NR4A3,
TGF/NR4A3
TPM3/ALK, TPM4/ALK,
CLTC/ALK, RANBP2/
ALK, CARS/ALK
FUS/CREB3L2, FUS/
CREB3L1
NF1
FUS/DD1T3, EWSR/DD1T3
SMARCB1
SYT/SSX
CSF1
Table 3 Major types of soft tissue sarcomas in adults

Tissue of origin
Fibrous tissue
Fat
Muscle
Striated muscle
Smooth muscle
Blood vessels
Lymph vessels
Synovial tissue (linings of joint
cavities, tendon sheaths)
Peripheral nerves
Cartilage and bone-forming tissue
Type of cancer
Fibrosarcoma
Malignant fibrous histiocytoma
Dermatofibrosarcoma
Liposarcoma
Rhabdomyosarcoma
Leiomyosarcoma
Usual location in the body

Arms, legs, trunk
Legs
Trunk
Arms, legs, trunk
Arms, legs
Uterus, digestive tract
Hemangiosarcoma
Kaposis sarcoma
Lymphangiosarcoma
Synovial sarcoma
Arms, legs, trunk

Legs, trunk
Arms
Legs
Malignant peripheral nerve sheath tumor/

neurofibrosarcoma
Extraskeletal chondrosarcoma
Extraskeletal osteosarcoma
Arms, legs, trunk

Legs
Legs, trunk (not involving
the bone)
393
imaging. PET scans have also been used to help

and more accurately stage STS (Figs. 1, 2,
and 3). However, what is interesting is that a
recent meta-analysis has disputed the benefit of
use of PET imaging in its current state, especially in low-grade tumors [20].
Following identification of what is believed to

be a soft tissue sarcoma, diagnosis with histological sampling becomes imperative. Percutaneous
core needle biopsy is often utilized, but it is
important to have a pathologist who is experienced in examining soft tissue sarcomas to make
the diagnosis. If core needle biopsy is unsuccessful in establishing a diagnosis, more extensive
procedures may be required. Having an accurate
diagnosis becomes critical in that it has been well
established that if surgery is to play a role in the
treatment of an STS, initial en bloc resection with
negative margins becomes critical. There are
numerous articles that have indicated that incomplete resection with positive margins has dire
effect on the overall local control and survival of
these patients [21, 22].
Additionally, establishing not only the primary
tumor diagnosis but the size, lymph node involvement, and distant metastatic involvement allows
us to use the tumor-node-metastasis (TNM) staging system, developed both by the American Joint
Committee on Cancer (AJCC) for soft tissue sarcoma and the International Union Against Cancer
Fig. 1 Well-differentiated liposarcoma. Coronal plane Committee (UICC) to correctly stage these
patients and establish treatment goals (Table 4).
T1 sequence; arrow shows stranding within tumor mass
Fig. 2 Axial plane T2 sequence with fat suppression;

arrow shows high (bright) signal throughout cross-section
of tumor
Fig. 3 Large basal cell carcinoma of scalp vertex
J. Fontanesi et al.
394
Table 4 Descriptions of stages, grades, and the tumor-node-metastasis (TNM) system of the American Joint Committee
on Cancer for soft tissue sarcoma and the International Union Against Cancer committee
Grade
And TNM
G1
G2
G3
G4
T1
T1a
T1b
T2
T2a
T2b
N1
M1
Description
Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated
Tumors 5 cm in largest dimension
Superficial to deep fascia
Deep to deep fascia (includes
retroperitoneal, intrathoracic and
most head and neck tumors)
Tumors >5 cm in largest dimension
Superficial to deep fascia
Deep to deep fascia(includes
retroperitoneal, intrathoracic and
most head and neck tumors)
Regional nodal metastasis
Distant metastasis
T1a
T1b
T2a
T2b
Stage
lA
llB
G1or G2
G3 or G4
N1
M1
Treatment of Adult STS
Once the diagnosis of soft tissue sarcoma has

been made, surgical intervention often becomes
the center piece of therapy. While amputation
was once considered the only surgical approach
available for extremity soft tissue sarcomas, a
report from Rosenberg et al. showed that the use
of limb savage had equivalent local control rates
to amputation [23]. Because of this study and
others that followed, limb savage became more
common. Soon after, other reports began to identify poor prognostic factors for local control; the
chief among these was a positive surgical margin.
Based on these citations, others followed with
reports on adjunctive therapies such as chemotherapy and radiation, either alone or in combination, in efforts to mitigate these factors [23, 24].
However, surgical margin status is not the
only prognostic factor that is considered important. Size of the tumor (less than or greater than
5 cm), tumor grade (high versus low), location,
and histological subtype are just a few of the factors that must be considered when treatment of
Stage
I
II
III
IV
lB
llC
IIA
lll
IV
5 YR survival
%
86
72
52
10-20
soft tissue sarcoma is decided upon. In fact,

several of these criteria are included in the AJCC
staging system for soft tissue sarcomas [25, 26].
While it is widely accepted that high-grade
tumor designation is a significant prognostic factor, marginal status has more recently come under
reinvestigation with several authors questioning
the influence of the notion of (positive) margins
and the eventual ability to establish local control.
Both Baldini and Curtis have reported that margin status did not affect local control [27, 28].
As noted, multiple clinical trials have been
reported using both pre- and postoperative chemotherapy alone or in combination with radiation. Radiation has also been evaluated in the
preoperative setting or in conjunction with (boost)
radiation therapy usually based on surgical margin status. Postoperative radiation by itself has
also been evaluated. It is interesting to note that
regardless of what additional therapy is employed
in conjunction with surgical intervention, local
control rates appear to be very similar (Table 5).
There have also been recent clinical reports
which have looked at how radiation is delivered
2014
2014
2012
2013
2013
2013
2011
2001
Folkert [31]
Dincbas [33]
Mullen [34]
Look- Hong [35]
Cai [30]
Felderhof [36]
Curtis [28]
Trovik [37]
1613
112
164
118
66
48
60
319
Various
Various
Various pre-/post-op EBI/ctx

Surg post-op EBI (60 Gy)
MAID/EBI surg ctx boost
EBI
N/A
EBI
EBI
EBI for positive

margins
16 Gy for
positive margin
EBI for close/
pos margin
Preop EBI surg Y-ctx
CTX/preop/8 cm
EBI
Boost type
EBI
10 RT
Bx
Surg/pre
# Patients Initial TX/factors

61
Preop EBI/positive margin
EBI external beam irradiation, CTX chemotherapy, LF local failure, LC local control
Year
2014
Author
Pan [32]
Table 5 External/intraoperative radiation in treatment of soft tissue sarcoma
83 %
89 % 3 years
83 % 5 years
91 % at 5 years
83 % control
90 % MAID
91 % at 46 months
78 % at 5 years
IMRT 92 % 5 years
EBI 85 % 5 years
81 % 5 years
LC
100 %
5 years
N/A
20/66
Wound
complications
Gr III 6 %
Gr III/IV
21 %
34 %
Gr III
II 5 %
8 Gr III
3 Gr IV
()
Complication
N/A
LC with dose >60 Gy

LF age >50
Stage II histology
Complications with chemo/
radiation
Doubt LF cause distant mets
1 PT with myelodysplastic syndrome

death
LC/surv with MFH
CTX if >5 cm/high grade
Notes
Longer survival with
<5 cm
low-grade
boost
LF with IMRT

395
J. Fontanesi et al.
396
and its influences on the establishment of local

control. Some have evaluated the use of intensitymodulated radiation therapy IMRT and compared
it to more traditional treatment approaches. These
reports have shown that there appears to be
improved local control with the use of
intensity-modulated radiation therapy. Whether
this is due to the technical delivery or the ability to
increase the amount of dose delivered is unclear.
There have been several clinical reports in which
it has been shown that doses greater than 60 Gy
helped to improve local control [2931].
Based on multiple clinical reports and experiences, various national and international organi-
zations have met and issued recommendations/

guidelines that would assist physicians in their
approach to patients with soft tissue sarcomas.
These organizations included the National
Comprehensive Cancer Network (USA),
American Brachytherapy Society (USA), GEC/
ESTRO (Europe), British Sarcoma Group (UK),
and ESMO (Europe) [3842] (Table 6).
Despite having access to these guidelines
which are very similar in their recommendations, a recent report had some disturbing
conclusions. Bagaria et al. reported that
despite NCCN recommendations of no postoperative radiation for stage 1 tumors, 25 % of
Table 6 Radiation recommendation for selected published guidelines

ESMO [38]
2014
ABS [39]
2013
British Sarcoma
Group [40]
2010
GEC/ESTRO [41]
NCCN [42]
Low/high grade; superficial; 5 cm

Low grade; deep; 5 cm
Close/positive margin
LR after previous surgery
Lesion 5 cm
Lesion deep to/invading superficial
fascia
High grade
50 year
Intermediate/high grade
Low grade; >5 cm; positive margins
5050.4 at 1.82 Gy
External beam
Boost to 66 Gy
Table 3 from ABS paper P 186
50 Gy at 2 Gy/Fx
6066 Gy
Preoperative
Postoperative
Low grade; >5 cm; positive margin

Intermediate/high grade
Local recurrence
6070 Gy at
4060 Gy/HR :
7080 Gy/2535 from
brachy tx :
LDR
Preop
50 Gy surg
Post-op for positive margins

50 Gy +
Combined EBI/brachy
1618 Gy EBI (M)
2026 Gy EBI (G)
1618 Gy LDR (M)
2026 Gy LDR (G)
1416 Gy at 34 Gy
BID HDR (M)
1821 Gy at 34 Gy
BID HDR (G)
1012.5 Gy 10 RT (M)
15 Gy 10 RT (G)
1016 Gy boost
(negative margin)
1618 Gy boost (M)
2026 Gy boost (G)
10 RT 1016 Gy + 50 Gy
LDR 1020 Gy (positive margin)
OR
] 50 Gy EBI
HDR 1416 Gy (positive margin)
LDR 45 Gy (negative margin)
HDR 36 Gy (negative margin)
M microscopic margin, G gross margin
these patients were eventually treated. More

concerning was that only 60 % of those in whom
a recommendation for postoperative irradiation
was appropriate actually received it, proving
again that you can lead a horse to water but you
cannot make it drink [32].
Implant Technique at Institut GustaveRoussy (IGR)
Soft tissue sarcomas: Adult

Technique
In the majority of cases, brachytherapy
(BT) is performed during the surgical
procedure. The plastic tubes are implanted
perpendicularly to the surgical incision.
The implant follows the Paris system rules,
that is, with the after loading tubes
equidistant, parallel, and spaced 12 cm
apart. The CTV is determined according to
the preoperative MRI and in consideration
of the surgical and pathological findings.
For LDR BT alone, prescription dose is
between 60 and 75 Gy delivered in
approximately 1 week (3540 cGy/h). In
cases of BT used as a boost, the dose ranges
between 25 and 35 Gy at the same dose
rate. For HDR BT boost, we follow the
recommendations of the ABS with a dose
range from 10 to 15 Gy.
Results
Comparison between HDR and LDR
BT yields a mean local control of about
80 % with variable complication rates.
Soft tissue sarcoma: Pediatric
Knowing the therapeutic possibilities
offered by brachytherapy in STS for adults,
the question is: Is it possible to adapt this
modality in children? Although spectacular
progress has been realized in chemotherapy
as well in external beam irradiation, brachytherapy can also play a specific role in conservative treatment of STS in pediatric
malignancies. Brachytherapy delivers irradiation with a very high dose gradient allowing a diminution of dose to the healthy
397
structures and we know that in a child the

growing,
normal
tissue
is
very
radiosensitive.
At the Institut Gustave-Roussy, more
than 50 years ago, the first BT in pediatric
malignancies was realized by Chassagne,
then by Gerbaulet, and now by HaieMeder and their colleagues. Many articles
and books were published during this past
half century, and our experience is essentially based on the use of LDR BT
(replaced recently in few patients by PDR
BT). In all cases, the Paris system rules
were applied for interstitial BT. For endocavitary BT, the recommendations of
ICRU 38 were applied. More recently, the
GEC-ESTRO recommendations are used
to specify doses to the tumor, to the critical organs, volumes (GTV, CTV), dose
rate, etc.
Four main tumor sites are individualized: trunk and limbs, head and neck, gynecologic, and prostate and bladder
Trunk and limbs
Perioperative BT is used in practically
all cases and performed according to tumor
surgical resection. In cases of an R2 resection, BT is applied as an anticipated boost
of 2530 Gy before external beam radiotherapy (EBT) (4045 Gy). In cases where
BT is used as monotherapy, LDR BT delivers a complete dose of 5060 Gy.
Head and neck
In the example of sarcomas of the nasolabial sulcus (a frequent rhabdomyosarcoma [RMS] site), two afterloading
systems scan be used, individually or
together. Silk threads are used for very
superficial lesions, and plastic afterloading
tubes for the rest. Usually 35 threads/
tubes are implanted and spaced at of
11.5 cm. The delivered dose with LDR
BT is 5560 Gy, with PDR BT: 4045 Gy
at 50 cGy per pulse, one pulse per hour. For
a child younger than 7 years of age, the use
of PDR is not recommended.
J. Fontanesi et al.
398
Gynecologic
For adult patients, the molded applicator
devised by Chassagne is usually used, and
made specially to order for each girl, which
is essential for vaginal-cervix tumors. That
allows conformality to tumor topography
and to adapt patient by patient the positioning of future radioactive sources. The dose
calculation can be complex and may
depend on the treatment planning system.
For LDR BT, the total dose is 60 Gy with a
dose rate of 0.40.6 Gy/h.
Prostrate and bladder
The perioperative BT starts as a conservative procedure: tumor resection with partial prostatectomy and/or partial cystectomy
in some cases but in all cases urethra preservation. Brachytherapy can be performed
for bladder tumor alone by a suprapubic
approach; however, the perineal approach
is more often used to implant plastic tubes
in a loop technique through the open pelvis. A dose of 60 Gy is delivered by LDR
BT. In cases of PDR, the same total dose
delivered as 4050 cGy per pulse and one
pulse per hour.
Results
Trunk and limbs: In this group of
patients the pathology more often is nonRMS, and represents less than 10 % of
children receiving BT. The results are
worse when compared to those observed
when compared to those observed in other
tumor sites: 3-year survival rate is 68 %,
local failure rate is 31 %; and metastases is
50 %. Still, we must focus on the high
level of salvage using BT: 36 %.
Head and neck: For all the groups of
children the local control approaches
80 %, but with a high level of sequelae rate
of 37 %.
Gynecologic: The 5-year OS rate is
91 %, while the complication rate decreases
when the target volume includes only
residual disease and not the initial tumor

volume.
Prostate and bladder: With a median
follow-up of 4 years (10 months14.5
years), 24 out of 26 boys are alive, 1 patient
relapsed locally (out of the BT target volume) and succumbed to disease.
5.1
Complications of Therapy
One of the drawbacks of the use of irradiation in

the pre- and postoperative setting is the issue of
side effects. Multiple series have reported on significant side effects associated with the delivery
of radiation. If one is serious about dose localization and the potential to lessen radiation-related
side effects, then brachytherapy becomes the
desired way to accomplish this goal. With that in
mind, there have been various clinical reports
which have utilized different brachytherapy techniques whether using permanent or temporary
applications and high-dose or low-dose rates.
Regardless of the dosimetric evaluations/prescription system used, the local control rates parallel those that have been reported with external
beam series often with reduced grade 3/4 toxicity
(Table 7).
There are those that dispute the advantages
of brachytherapy when compared to IMRT. A
series from Memorial Sloan Kettering in 2011
reported on 134 adults with high-grade
STS. Seventy-one received LDR brachytherapy
and the remaining patients were treated with
IMRT to a median dose of 63 Gy. The 5-year
local control was 92 % for the IMRT group and
81 % for the LDR group [51].
Others also dispute the need for any radiation
after limb-sparing surgery. Baldini et al. reported
on 242 patients with STS of the trunk and extremity [27]. If surgical margin was 1.0 cm, the local
control was 87 % compared with 100 % local
control with margins greater than 1.0 cm. This
has been reported by other groups [52, 53].
399
Table 7 Brachytherapy in treatment of soft tissue sarcoma

Author
Ren [43]
Year
2014
Patients Tx sequence
110
Surg I-125p
Rosenblatt [44]
2014
32
Petera [45]
2010
Itami [46]
Local control
74 % at 43
months
45
Surg Bx
EBI
Surg Bx EBI
87.5 % at 36
months
74 % at 5 years
Complications
Wound 4.5 %
Nerve
damage 1.8 %
Gr III/IV wound
16 %
>Gr II 4.4 %
2010
25
Surg Bx
78 % 5 years
>Gr II 11.5 %
San Miguel [47]
2011
60
Surg Bx EBI
77 % at 9 years
Gr III 30 %
Fairweather [48]
Alektiar [49]
2014
1996
46
105
Surg I-125p
Surg Bx EBI
74 % at 5 years
86 % at 2 years
Gr III/IV 24 %
Overall wound
2638 %
Youssef [50]
2002
60
Surg Bx/Bx
and EBI
71 % at 5 years
Pisters [51]
1996
164
Randomized
surg Bx
Beltrami [52]
2008
112
Bx/EBI
82 % Bx
69 % no Tx
at 5 years
91 % at 5 years
1 delay wound
healing
2 infection
N/A
12 %
Comments
LC with dose
65 Gy
50 % positive
margin with LC
DFS with tumor
>6 cm, positive
margin
LC with
Bx + EBI for
positive margin
LC with positive
margin
Limited advantage
for HG lesions
12.5 com
LC local control, EBI external beam irradiation, p permanent, HG high grade, Bx brachytherapy
Treatment of Pediatric STS
While similar treatment interventions are used

for pediatric non-rhabdomyosarcoma soft tissue
sarcoma, patients with RMS are frequently
entered into national clinical trials that are trying
to establish the best chemotherapy treatment,
often based on histological subtype. The main
difference in contemplating the use of radiation
in adults and pediatric patients with STS lies in
the concern related to potential second malignant
neoplasm (SMN) development in addition to the
local effects of irradiation such as impaired soft
tissue/bone development.
It is well established that the age at which a
child receives irradiation can have a profound
effect on soft tissue/bone growth especially if
treatment is given prior to the age of 7 [54, 55].
While these non-life-threatening side effects of
radiation can have a significant effect on the child,
of greater concern is the potential of a radiation- or

chemoradiation-induced SMN. These are life
threatening. This problem is compounded by the
fact that these children may be genetically predisposed to this development [56, 57].
When radiation is employed, there is a clear
difference in the doses delivered for those patients
who carry a diagnosis of RMS and for all other
non-rhabdomyosarcoma (NRS) soft tissue
sarcomas. The RMS doses rarely exceed 45 Gy,
while treatment of NRS soft tissue sarcomas can
include doses of up to 70.2 Gy [58]. There have
been reports detailing dose variation based on
surgical margin status. In the NRS soft tissue
sarcomas series that have been reported, local
control rates are similar regardless of dose and
parallel most adults series (Table 8).
Because of concerns about local toxicities and
the potential for second malignant neoplasm
development, the use of brachytherapy has been
J. Fontanesi et al.
400
Table 8 Pediatric external beam for RMS/NRSTS
Author
Krasin [58]
Year
2010
Patients
34 HG NRSTS
Rodeberg [59]
2014
Inter risk RMS
Cecchetto [60]
2000
25 RMS
27 NRSTS
Treatment scheme
Preop: 4550.4
Post-op: 5563
Defin 70.2
Brachy 45 Gy
Delayed primary
resection with
various dose
schedule
Various
Grade III/IV
complication Comments
47 % > Gr II 2 cm margin used
Fibrosis
47 % Gr II fibrosis
Local control
87 %
100 bladder
dome
93 % extremity
80 % trunk
8487 %
N/A
84 % Able to have
dose reduction
with delay
N/A
Worse LC with
CTX alone
Table 9 Pediatric brachytherapy series

Author
Gerbaulet [61]
Year
1985
# Patients
58
Fontanesi [62]
Merchant [63]
1994
2000
46
31
Ptter [64]
1995
18
Martelli [65]
2009
Viani [66]
2008
26
(Bladder)
RMS
18
Folkert [67]
2014
75
Treatment
scheme
CTX BX
Various
12 BX
19BR + EBI
BX
BX + EBI
Resect BX
HDR
HDR + EBI
HDR/10 RT
812 Gy
Dose utilized
6065 Gy/57
days (L)
LDR
LDR
Med F/U
60 months
Local control
78 %
39 months
HDR/1543 Gy/
316 FX
PDR 13-36 Gy/1 h
fraction
LDR
(60 Gy)
14 months
86 %
100 BX alone
13/14 LC BR/EBI
STS 9/12
Ewing 6/6
48 months
25/26
HDR
79 months
HDR
7.8 years
8/8 HDR
9/10 HDR/EBI
63 % initial
46 % for relapsed case
CTX chemotherapy, PDR pulsed dose rate, Bx brachytherapy, EBI external beam irradiation
investigated. It has a rich history of utilization for

more than 30 years and has shown excellent local
control rates with acceptable local toxicities and
what appears to be a low rate of second malignant
neoplasms (Table 9).
Technical Aspects
of Brachytherapy
in the Treatment of STS
With few exceptions, the use of brachytherapy

for both adult and pediatric STS is done in an
operative theater during the definitive surgical
procedure. It is critically important to have

coordination with the surgeon and rehabilitation
physicians when it comes to limb salvage procedures. This is key in that is allows for better
understanding of how the wound will be closed
and what strategies to employ in order to get the
patient as much future function as possible.
During the surgical procedure, we prefer to
have the surgeon outline the gross tumor volume
with surgical clips. We request that this be done in
at least four positions: proximal, distal, medial,
and lateral. If there are special areas that need to be
identified, special clip arrangements, such as using
double surgical clips, can be utilized. We will
request from the pathologist information on the

margins to determine positivity or negativity.
We strive for negative margins where possible.
This helps with catheter placement decisions.
Next we pay attention to wound closure. Often
tissue has to be undermined in order to affect a
primary closure. It is critical for the radiation
oncology team to understand how the closure is
to take place as it may affect how catheters/seeds
are placed.
Once the closure is identified and discussed,
we will place the catheters. Generally we will use
either a horizontal (perpendicular to wound) or
vertical (parallel) catheter placement strategy. In
general, the horizontal placement strategy will
result in more catheters being placed than in the
vertical technique. We always try to place the
center or middle catheter first and then proceed to
place the remaining catheters at 11.5 cm
spacing. With each catheter placement, we reassess the wound closure and make adjustments as
needed. The catheter will then be secured in
either two or three sites with absorbable suture
material (we prefer 6-0 chromic suture). In this
way we assure that when the closure takes place,
the surgeon is aware of the geometry we are trying to achieve. We do not cut any catheter that is
extending outside the skin surface until simulation is completed. At that time, if we are using
HDR techniques, we make sure 45 cm extends
from the skin surface. If LDR techniques are
being utilized, we like at least 2 cm from the skin
surface from the side that is to be loaded.
One of the critical decisions that are made is
the implant volume to be treated and the catheter
placement technique. The two most common
catheter placement techniques are the buried
technique, where one side of the catheter is blind
ended (see Skin chapter) and is buried in one of
the margins. This is usually 25 cm beyond the
clips that have been placed by the surgeons. The
second technique employs a through and through
technique where both ends of the catheter can be
utilized, although blind-ended catheters can also
be used effectively.
Our next step is to perform a CT simulation
and treatment planning. We try to do this as soon
401
as the surgical team will allow the patient to be

brought for evaluation. We also try to ensure that
the treatment site is stabilized. This usually
occurs 2448 h after surgery.
Much has been discussed regarding how soon
treatment should be initiated. In general we wait
for final pathology report to make sure no unusual
findings are reported that may alter the
brachytherapy decision. If none occur, we start
the treatment as the treatment plan is ready and as
long as the surgeons are OK with treatment
proceeding. Some groups have suggested waiting
for up to 7 days before treatment initiation in an
effort to reduce wound complications. We believe
treatment can be initiated earlier than that, even
within 72 h, so long as the surgical team approves.
We are concerned that waiting a full 7 days to
initiate treatment may allow a longer access
time for infection to occur even in the face of
antibiotic coverage. In addition if one extrapolates
from the keloid brachytherapy postoperative
data, there is little chance of wound dehiscence
when treatment is introduced within 24 h as most
of fibroblast depositions for wound closure take
place in the first 2448 h.
Various brachytherapy dose recommendations
have been used in both adult and pediatric
STS. They are noted in Tables 6, 7, and 9.
Our group most frequently utilizes HDR
techniques. The following table outlines our
usual recommendation. Note that we try to
keep less than 50 % of the treatment volume
from receiving 125 % or more of the prescribed
dose.
Brachytherapy
type
Situation
HDR
Dose/FR # Fx Schedule
Monotherapy 325350 12
BID
Or
Boost
600800 6
QD
325350 6
BID
Or
600800 3
LDR
QD
Monotherapy 4250/
HR
N/A 60 Gy
total
Boost
N/A 1624 Gy
total
3545/
HR
J. Fontanesi et al.
402
Conclusion
Soft tissue sarcomas present unique challenges to both the patient and treating physician team.
They are unique in that they are age independent, have 50 plus subtypes, and in general
their aggressiveness is tied to tumor grade.
Soft tissue sarcomas have varied rates of
regional (lymphatic)/distant spread, and their
presentations are also quite varied. The treatment of soft tissue sarcoma has evolved from
amputation first to limb salvage/preservation
if possible. In order to improve local control,
various adjunct therapies have been introduced. Chemotherapy and radiation have been
used in the pre-/postoperative setting with
various reported success.
One of the most consistent prognostic factors
besides tumor grade has been resection margin
positivity but even that has been challenged.
With various opportunities to interdict with
radiation, there have been advocates and detractors of both external beam and brachytherapy
techniques. However, there is no disputing the
greater dose profiling that brachytherapy offers.
The main drawback of brachytherapy has been
historically related to patient hospitalization
requirements for low-dose radiation techniques. However, with high-dose radiation
techniques, these issues are mitigated.
Brachytherapy for soft tissue sarcoma
requires excellent coordination with the surgical oncology and rehabilitative service participants. This helps the brachytherapist to best
understand functional expectations postoperatively and allows for better radiation treatment
planning. In general, it is best if patients
receive treatment at centers that have dedicated orthopedic/surgical oncology teams that
work closely with experienced medical and
radiation oncologists and are supported by
strong ancillary service teams that recognize
the unique challenges which patients with soft
tissue sarcoma present.
Acknowledgements The authors wish to thank Susan
King for her assistance in the editing and preparation of
this chapter.
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Index
B
Brachytherapy
contact, 340, 341, 343
endoluminal, 209218, 344
endovascular,
interstitial, 3, 14, 32, 42, 342, 350, 351,
353, 354, 371, 391
intracavitary, 3, 14, 79, 91, 93, 101, 125, 128, 164, 169,
173, 197200, 264, 266, 268, 274, 290, 351
mould, 14, 80, 378
D
Dose rate
HDR
balloon, 41, 42, 46, 55, 57
boost, 226, 324325, 395
breast, 4
definitive, 212215
GYN, 4, 6
prostate, 313330
LDR
afterloading, 3
preloading, 15
remote afterloading, 15, 45, 209
PDR
biology, 314
pulses frequency, 103
pulses interval, 72
Dose volumes
BTV, 10, 392
CTV, 10, 47, 48, 53, 96, 99, 101, 102, 182, 185, 186,
196, 237, 250, 251, 255257, 259, 260, 265,
267, 274276, 287, 298, 299, 305, 319320,
341, 351353, 364, 368, 376, 391
GTV, 10, 53, 59, 81, 96, 99, 100, 256, 259, 265, 274,
275, 281, 287, 298, 320, 341, 351, 368, 391
high dose volume, 146, 157
PTV, 10, 24, 42, 49, 50, 53, 56, 58, 65, 96, 102,
144147, 153155, 158, 168, 170, 172,
182184, 196, 237, 239, 240, 298, 316,
320, 322, 323, 368, 376
treated volume, 342, 376

Dosimetric systems
GYN historic
Manchester, 6, 7
Paris, 6, 7
Stockholm, 6, 7
Manchester
double crossing,
sources activity, 7
sources distribution
centre,
isotope specific energy, 8
periphery, 7, 299
surface, 7
volume, 7
nomograms
192
IR ribbons, 30, 72
125
I seeds, 3, 16, 29, 3134, 36, 38, 71, 107,
219, 220, 295
103
Pd seeds, 32, 38
Paris
active lines number
length, 6
spacing, 96
surface, 196, 342
volume, 353
multiple sources dosimetry, 371
single source dosimetry, 371
Quimby
sources activity, 8
sources distribution, 7
Dosimetry
implants quality assurance,
180, 309
legislative norms and regulations,
103, 360, 372
safety regulations
AAPM, 22, 32, 37, 51
GEC ESTRO, 95, 97
sources calibration, 31
sources physics, 3437
sources quality control, 303

DOI 10.1007/978-3-319-26791-3
405
Index
406
E
Eye
contact plaques
adverse events,
60
Co, 64
125
I, 65
results,
106
Ru, 63, 64
G
Genitourinary
bladder
adverse events, 325
results, 324, 325
prostate
permanent seeds
125
I
boost
adverse events, 325
results, 324, 325
definitive, 324, 325
interstitial HDR
boost
adverse events, 325
results, 324
definitive, 325
103
Pd
boost
adverse events,
results, 305
definitive,
Guidelines
ABS, 95, 102, 198, 266268, 295, 298, 303, 315, 320
ASTRO, 140
ESTRO, 51, 57, 304, 305, 315, 320
GEC-ESTRO, 96, 102, 267, 350
GEC-ESTRO-ABS, 281, 287, 289
NCCN, 248
I
Imaging
CT, 10, 24, 36, 43, 47, 48, 58, 93, 94, 103, 143, 144,
146, 147, 155, 158, 168, 181182, 185, 186,
196, 250, 251, 259, 268, 283, 286, 288, 289,
295, 305, 315, 317, 350, 385
image fusion, 10, 235, 305
machines
remote afterloading HDR, 15, 45, 85, 96, 104105,
211, 212, 219, 221, 222, 225, 236, 316
remote afterloading LDR, 15, 72, 209
remote afterloading PDR, 93, 158, 267
MRI, 10, 24, 91, 93, 102, 129, 157, 186, 196,
234237, 242, 243, 254256, 258, 259,
264268, 274, 275, 281286, 288, 289,
291, 295, 298, 305, 306, 315318, 320,
349, 352, 353, 356, 385, 391
PET, 10, 208, 224, 254, 258, 264, 274, 283, 285, 387
x rays
orthogonal films, 100, 250, 265
P
Permanent implants
125
I
boost, 38
definitive, 16
energy, 9, 31, 219
half life, 9, 31, 219
MPD, 242, 303
103
Pd
energy, 9, 31, 82, 219
half life, 9, 31, 185, 219
MPD, 303
R
Reference systems
ICRU points, 7, 257, 260
image guided brachytherapy
V0.5,
V01,
V02,
V20,
V50, 46, 55, 148
V90, 58, 59, 148
points
A, 7, 287, 289
B, 7, 287, 289
bladder point, 265
rectal point, 37, 257, 296
S
Safety regulations
AAPM, 22, 32, 37, 51
GEC-ESTRO, 95, 97
legislative norms and regulations, 103, 360, 372
Skin
contact
interstitial, 140
Leipzig applicator
adverse events, 154, 368
results, 367
moulds, 80, 264, 368
Sources
252
Cf, 9
137
Cs, 9, 30, 31, 51, 57
125
I, 9, 31, 57, 6467, 186, 242
192
Ir, 8, 9, 30, 31, 44, 46, 47, 51, 52, 57, 142,
166, 237, 267
low energy X rays, 37, 345
103
Pd, 9, 31, 57, 64, 182, 186
226
Ra, 5, 6, 8, 9, 30
Yb-169, 46
T
Technique
dose rate
HDR, 99, 141, 149, 150, 219
LDR, 20, 99, 150, 153, 157
PDR, 99, 153, 157
Index
modality
boost, 140, 226, 315, 325, 326
definitive, 140, 142, 187, 212, 213
tools
balloon
multiple active lines, 42
single active line, 43, 284
hairpins, 85, 89
loop, 89
needles, 85, 86
plastic tubes, 89
Tumor sites
anus
anal canal
interstitial
results, 353
intracavitary, 351
anal verge
interstitial
adverse events, 348
results, 348
intracavitary, 349
breast
balloon, 140
interstitial, 140
mammosite, 166, 168
multicatheter balloon
results, 169, 172, 173
bronchi
interstitial, 218
intraluminal
adverse events, 223
results, 226
esophagus
intraluminal
boost, 225
palliative
adverse events, 226
results, 227
gynecology
endometrium
intracavitary
HDR
adverse events, 260
results, 260
LDR, 259, 260
local relapses
interstitial
adverse events, 199
results, 199
intracavitary, 197
uterine cervix
interstitial
combined intracavitary and
interstitial
Utrecht applicator
adverse events, 285
results, 284
407
Wien applicator, 150
template
MUPIT
adverse events, 290
results, 289
Syed-Neblett, 290
intracavitary
HDR
BED, 115
fractions number, 103, 104
fractions size, 97, 100, 102, 128
timing, 98
LDR
after loading, 391
interstitial template
adverse events, 392
results, 391, 392
remote after loading, 267
PDR
BED, 314
fractions interval
adverse events, 256
results, 257
fractions size, 314
number of fractions, 252
vagina
intracavitary
interstitial
adverse events, 242
results, 252
head and neck
lip
adverse events, 74
results, 76
nasopharynx
adverse events, 100
results, 125
oral cavity
cheeks
adverse events, 368
results, 369
floor of the mouth
adverse events, 105
results, 105
gum
adverse events, 75
results, 76
mobile tongue
adverse events, 123
results, 123
oropharynx
base of the tongue
adverse events, 90
results, 91
retromolar trigon
adverse events, 99
results, 98
tonsil
adverse events, 76
results, 76
Index
408
Tumor sites (cont.)
liver
biliary tract
choledochal, 238
extra hepatic, 239
intra hepatic, 240
ERCP intra luminal
choledochal, 79
extra hepatic, 65
intra hepatic, 65
percutaneous intra hepatic intraluminal
adverse events, 242
results, 240
pancreas
125
I permanent implants, 9, 29, 37, 38
192
Ir duct intraluminal
adverse events, 242
results, 241
rectum
interstitial, 341
intracavitary
adverse events, 351
results, 342

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Medical Radiology Radiation Oncology

Series Editors: L.W. Brady S.E. Combs J.J. Lu

For further volumes:

Paolo Montemaggi Mark Trombetta

My professional life has been inspired by two main figures to

Special thank you: Information Technological assistance

The Physics of Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physics: Low-Energy Brachytherapy Physics . . . . . . . . . . . . . . . . . .

Balloon Brachytherapy Physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Disease Site Specific Topics

Breast Brachytherapy: Interstitial Breast Brachytherapy . . . . . . . . 145

Thoracic Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Beth A. Erickson Department of Radiation Oncology, Medical College of

Vincenzo Valentini Gemelli ART (Advanced Radiation Therapy), Catholic

The second half of the nineteenth century was a

physics in 1901. It was quickly recognized that

Springer International Publishing Switzerland 2016

skills began to accumulate more rapidly than the

T.E. Yaeger et al.

daughter product radon, captured in glass tubes

armamentarium. Many have been developed to

intracavitary, or topical molds (plaques) either

catheters within the safety of a radiation-protected

T.E. Yaeger et al.

safe, and computer-controlled radiation delivery

Brachytherapy: A Journey of Hope

is in our history, in our past, and in its knowledge

Springer International Publishing Switzerland 2016

P. Montemaggi and P. Guerrieri

Following these themes, we will review our

The Search for Dose

The earliest attempts to use the newly discovered

they were based on. It is not only important that

Brachytherapy: A Journey of Hope in the Battle Against Cancer

The long journey to find the best way to use

P. Montemaggi and P. Guerrieri

needles, Quimby proposed the use of sources of

The Search for Strategy: New

Table 2 Radium substitute characteristics (ideal)

topes in development should have specific

Brachytherapy: A Journey of Hope in the Battle Against Cancer

the development of a new treatment strategy.

high-dose rate techniques for which specific

P. Montemaggi and P. Guerrieri

The Search for Volume:

As it has been with the advent of new external

struction of the anatomy and the functionality of

Table 4 Volumes of interest and related imaging techniques

fMRI PET Image fusion

Brachytherapy: A Journey of Hope in the Battle Against Cancer

nent role and how still important brachytherapy

The Physics ofBrachytherapy

Physics has wide application in brachytherapy.

L.K. Schubert, PhD (*) M. Miften, PhD,

that can be applied to decision making in practice.

Brachytherapy is classified according to how

Springer International Publishing Switzerland 2016

L.K. Schubert and M. Miften

Brachytherapy is classified according to how

Source Loading Technique

alf-Life, Mean Life, Effective

adioactive Sources Used

actors That Influence

Dose Calculation Methods

Cumulative Dose Calculations

APM TG-43: Modular

Image-Based Dose Calculation