Brachytherapy
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Brachytherapy (from the Greek brachy, meaning "short"), also known as sealed source radiotherapy or endocurietherapy, is a form of radiotherapy where a radioactive source is placed inside or next to the area requiring treatment. Brachytherapy is commonly used to treat localized prostate cancer[1][2], cervical cancer [1] and cancers of the head and neck.[3] Brachytherapy to prevent restenosis after stenting associated with coronary angioplasty has been proven safe and effective in clinicals trials, such the START and START 40/20 Trials.
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[edit] Types
Brachytherapy exists in numerous forms:
- Mold brachytherapy. Superficial tumours can be treated using sealed sources placed close to the skin. Dosimetry is often performed with reference to the Manchester system; a rule-based approach designed to ensure that the dose to all parts of the target volume is within 10% of the prescription dose.
- Strontium plaque, used for very superficial lesions less than 1 mm thick. The plaque is a hollow, thin silver casing that encloses a radioactive strontium-90 powdered salt. The beta (electron) particles produced from strontium's radioactive decay have a very shallow penetration. Typically the Sr-90 plaque is placed on the bed of a resected pterygium. A stat dose of around 10-12 Gy is delivered by timing the contact. As the electrons only penetrate a few mm of air, radiation protection issues are slightly less but very different from other radiation sources. Cleaning the plaques that are placed on the eye sclera is required but must be gentle because the silver casing is thin and easily damaged. Strontium belongs to the same chemical class as calcium, i.e., an alkaline earth metal, and so will co-locate in the bone if any strontium salt makes contact with the eye and is absorbed. Operators can prevent exposure to the beta rays by facing the applicator away from their bodies.
- Interstitial brachytherapy. Here the sources are inserted into tissue. The first treatments of this kind used needles containing radium-226, arranged according to the Manchester system, but modern methods tend to use iridium-192 wire. Iridium wire can be arranged either using the Manchester or the Paris system; the latter was designed specifically to take advantage of the new nuclide. This also includes the removal of small lung cancers through wedge resection followed by placement of a brachymesh device, consisting of absorbable suture containing iodine-125 seeds to reduce the risk of recurrence. LDR prostate brachytherapy treats prostate cancer using iodine-125 or palladium-103 seeds . This latter treatment type differs from other interstitial treatments as the sources are left in the prostate permanently, rather than being removed after the intended treatment time. For details of the gamma emitters please see commonly used gamma emitting isotopes.
- Intracavitary brachytherapy places the sources inside a pre-existing body cavity. The most common applications of this method are gynaecological in nature,[2] although it can also be performed on the nasopharynx.
- Intravascular brachytherapy places a catheter inside the vasculature through which sources are sent and returned. The most common application of this method is the treatment of coronary in-stent restenosis, although the therapy has also been investigated for use in the treatment of peripheral vasculature stenoses and also considered for the treatment of atrial fibrillation. Although a few systems have been used successfully for intravascular brachytherapy, the only device currently available is the Novoste Beta-Cath System from Best Vascular, Inc. which uses beta-emitting sources of Sr/Y-90.
- Electronic brachytherapy places a miniature low energy (< 50kVp) x-ray tube source into a pre-positioned applicator within body/tumor cavities to rapidly deliver high doses to target tissues while maintaining low doses to distant non-target tissues.
[edit] Dosing
Brachytherapy can be applied using different dosings.
[edit] Low dose rate
Low dose rate (LDR) involves implanting radioactive material temporarily or permanently. It is commonly used for cancer of the oral cavity and oropharynx and sarcoma, as well as prostate cancer.[2]
[edit] High dose rate
High dose rate uses a dose of 20 cGy per minute or above (ICRU 38). A high dose rate source (often iridium-192, Ir-192) is the material used. HDR is an alternative to LDR in cases where it can be administered without a large number of fractions.[4] The most common applications are for tumors of the vaginal apex, esophagus, lungs, breasts, and prostate. Most HDR treatments are outpatient; however, patients with prostate cancer may remain in the hospital for 2-3 days during treatment.[2]
[edit] Side effects
There are many side effects associated with brachytherapy treatment of the prostate using seeds, most of these are urinary in nature and are short lived. However, between six and fifty percent of patients (depending upon the seriousness of the cancer) may become infertile or impotent following brachytherapy.[citation needed] Another side effect can occur as a consequence of migration of seeds out of the treatment region; it is therefore important to filter urine so as to recover the radioactive seeds.
[edit] Application
Brachytherapy can be applied manually, or remotely using machines. Historically, manual application resulted in doctors being exposed to excessive levels of radiation. The procedures can be performed with temporary or permanent implants.[2] Later restrictions on radiation exposure resulted in the development of remote afterloading, which delivers the radioactive materials from a safely contained source via hollow tubes. The motor to push the materials is engaged once staff are removed from the treatment room. Modern high dose rate therapies for relatively thin target volumes include the interstitial and intracavitary use of beta emitting isotopes as well as low energy x-rays to achieve high target doses with tissue sparing low non-target doses and reduced exposure levels to users.
[edit] See also
[edit] References
- ^ a b Merrick GS, Butler WM, Wallner KE, Galbreath RW, Adamovich E (2005). "Monotherapeutic brachytherapy for clinically organ-confined prostate cancer". W V Med J 101 (4): 168–71. PMID 16296198.
- ^ a b c d e Camphausen KA, Lawrence RC. "Principles of Radiation Therapy" in Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach. 11 ed. 2008.
- ^ Mazeron JJ, Noël G, Simon JM, Racadot S, Jauffret E (February 2003). "[Brachytherapy in head and neck cancers]" (in French). Cancer Radiother 7 (1): 62–72. PMID 12648718. http://linkinghub.elsevier.com/retrieve/pii/S127832180200286X. Retrieved on 2008-05-23.
- ^ Manimaran S (June 2007). "Radiobiological equivalent of low/high dose rate brachytherapy and evaluation of tumor and normal responses to the dose". Radiat Med 25 (5): 229–35. doi:. PMID 17581712.
[edit] External links
- The GEC ESTRO Handbook of Brachytherapy
- 3D illustration of how the procedure is commonly performed for prostate cancer
- Social community focused on breast brachytherapy
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