1. Technological advances in Brachytherapy
Ekkasit Tharavichitkul, MD The Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chiang Mai University

2. History Greek word = short –Interstitial brachytherapy
–Contact brachytherapy
→ surface mould BT
→ intracavitary BT
→ endolumina BT

3. Brachytherapy history
1896: Becquerel
1898: MarieSklodowska-Curie
1901: Danlosand Block: Paris
1905Abbe: US Radium implantations

4. Different empirical methods and rules
•Stockholm method for Gyne (1914)
•Paris method for Gyne (1919)
•Manchester system (1934) Paterson-Parker, Meredith
•Paris System for IS : Pierquin, Chassagne, Dutreix

5. Discovery of artificial radioactive isotopes
• 1934 Irene Curie -FrédericJoliot
• 1958 Iridium-I92: U. Henschke
Development of afterloading concept
• U. Henschke-D. Chassagne
Developmentof 3D dosimetry and fundamental rules of dosimetry
• B. Pierquin-D. Chassagne-A. Dutreix

6. Brachytherapy

7. Developments in BT Source and loading methods Imaging developments
Applicator developments
Planning developments
Clinical research developments

8. Source and loading method

9. Radioisotope sources and loading methods
From Radium --- Iridium
From LDR --- HDR --- PDR
From manual loading to remote after- loading

10. Radium--Iridium

12. Manual and remote loading

13. LDR vs. HDR พารามิเตอร์ LDR HDR Dose rate < 2 Gy/ชั่วโมง
Problem of radiation hazard + -
Discomfort
+++
Unexpect shift of applicators
Ward
Number of patient per day 1
มากกว่า 1 ราย
Time for loading
ชั่วโมง
นาที
Cost of machine

14. Manual or remote control afterloading
Gynecological applicators
Guide needles: straight and curved
Plastic tubes
Moulds
Hypodermic needles
Silk wires
Endo-luminal catheters
• Remote control afterloaders

15. Imaging

16. Imaging developments Modern imagingtechniques: -US, CT, MRI
• 3D dosimetry
-More accurate dose distribution
-DVH relation to outcome for target + OAR

17. X-ray base

18. Ultrasound guidance

19. U/S guidance

21. Applicators

22. Applicator developments
More compatible with imaging
CT/MR applicator
Gynecological cancers
Plastic catheter
Breast cancer
Prostate cancer

23. Standard applicators
Nucletron.com

24. Scatter; metallic applicator

25. CT/Applicator

26. Breast BT
mammosite
Multicatheter
Clearpath
Polgar, 2009

27. Volume concepts

28. Volume concepts 1985 ICRU 38 :Gynecological brachytherapy
1997 ICRU 58 :Interstitial and intraluminal brachytherapy
2000 GEC-ESTRORec: Prostate Permanent Implants
2001 GEC-ESTRO Rec: Endovascular brachytherapy
2005 GEC-ESTRORec: Prostate Temporary Implants
2005 GEC-ESTRORec: 3D-GYNE

29. Ultrasound

30. CTV prostate
GEC-ESTRO handbook,2002

31. Target volume: HDR

33. Volume concepts of cervix
CHM, 2005

34. Diagram of CTVs

35. 35

37. HR-CTV
Bladder
Rectum
Sigmoid

38. D90 HR-CTV
D2cc B
D2cc R
D2cc S

39. Chiang Mai

40. Breast cancer
Polgar, 2009

41. Planning developments

42. Planning developments
Shifting from 2D to 3D
Target volume definition
Algorithm: AAPM TG43 to Monte Carlo
Inverse planning
IPSA (Inverse Planning Simulated Annealing)
HIPO (the Hybrid Inverse Planning and Optimization)

44. Clinical studies

45. Cervix

47. Breast BT
Polgar, 2009

48. Clinical studies

49. EVL, Estro course 2008

50. Toxicity profile
Niehoff

51. Clinical developments
All RCTs
NSABP B-39/RTOG 0413 (4800 pts enrolled)
WBI 50 Gy plus boost to Gy versus Multicatheter (34Gy)/Mammosite(34 Gy) /3D- CRT(38.5Gy)
GEC-ESTRO working group trial (1170 pts enrolled)
WBI 50 Gy plus boost 10 Gy versus HDR and PDR
Pending for results 51

52. Conclusions
Modern brachytherapy which is high Ballistic selectivity and adaptivity is a competitive tool in the multidisciplinary treatment of cancer patients
A strong collaboration between
-Radiation oncologists
-Organ specialists
-Medical physicists
-Radiation technologists
is necessary to obtain optimal results for the patient(s)

53. Our researches: CT From July 2008 - Dec 2009
16 pts in CT-based planning in EBRT and BT
BT 6.5 Gy x Fx
GEC-ESTRO recommendations concepts
Image-guided planning (optimized plan) can reduced the dose to the bladder and sigmoid colon with compromised dose to the target

54. Our research:MRI From Feb 2009- nowadays
Planned 14 pts will be enrolled
MRI guided treatment: Dx, 1st BT, after treatment
With GEC-ESTRO recommendations
Now 6 patients finished
Pending results