High Dose Rate Remote

Afterloader Brachytherapy

AHEC 2006 1
Brachytherapy
came into use
soon after the
discovery of
radium by Marie
Curie in 1898.

2
Before the 1950's, the radioactive material
(mostly radium) was generally inserted
directly into the tumor (called hot loading) in
the operating suite.

3
“Manual afterloading”
“Manual afterloading” was
introduced to reduce the radiation
exposure
p hazard byy first inserting
g
hollow needles or tubes into the
tumor in the OR, transporting the
patient to a shielded room, and then
loading the radioactive material
through the tubes.
4
Rolf Sievert first proposed the concept of
“remote controlled afterloading” in 1937.
 Brachytherapy treatments
„ Brachytherapy treatments using
remote controlled systems began in
1964. Early systems used cobalt-60,
but the first Iridium
Iridium-192
192 machine was
introduced in 1966.

6
Dose Rates

Brachytherapy can be delivered at

very different rates, over a wide range
of treatment times varying from
minutes
i t to t months.
th Brachytherapy
B h th
dose rates have been divided into low,
medium, and high by the International
Commission for Radiation Units and
Measurements (ICRU) and published
in their report No. 38.
7
Low Dose Rate
„ Low Dose Rate (LDR): 0.4 to 2.0 Gy per
hour – This is the traditional dose rate for
permanent brachytherapy and manually
loaded temporary brachytherapy implants.
Th treatment
The t t t times
ti for
f the
th manually
ll loaded
l d d
temporary implants are typically 2 to 5 days.
Most of the long term clinical experience
with brachytherapy is with LDR implants.
The radiobiology of continuous low dose
rate irradiation is well understood and
documented in decades of clinical trials

8
Medium Dose Rate
„ Medium Dose Rate (MDR): 2.0 to 12.0 Gy
per hour – Also called intermediate dose
rate, this dose rate is rarely used in manual
afterloading because of the increased
exposure to t radiation
di ti workers.
k Th
The
radiobiology is not well understood. The
only current application is in Pulsed Dose
Rate (PDR) Brachytherapy. PDR
afterloaders expose a source for a few
minutes each hour, so that the average
dose rate per hour mimics LDR.

9
High Dose Rate
„ High Dose Rate (HDR): over 12.0 Gy per hour –
HDR Brachytherapy is only used with remote
afterloaders in well-shielded rooms. Very high
activity sources are used and produce very intense
radiation
di ti fifields.
ld ThThe advantage
d t iis th
thatt a specified
ifi d
dose can be delivered in minutes, instead of days,
and the patients are not required to remain in the
hospital (as is the case with LDR). Commercially
available HDR systems typically treat at a dose rate
of 100 to 300 Gy per hour.

10
 Title 10 CFR, Part 35.2 uses the same
definitions but lists the ranges as:

„ Low Dose Rate: less than or equal to 2 Gy

(200 rads) per hour
„ Medium Dose Rate: between 2 Gy (200
rads) and 12 Gy (1200 rads) per hour
„ High Dose Rate – greater than or equal to
12 Gy (1200 rads) per hour

at the point or surface the dose is prescribed.

11
Dose Rate
Sometimes dose rate is
specified in terms of
minutes. High dose rate is
greater than or equal to:
12 Gy/hr = 1200 cGy/hr = 1200 rads/hr = 20 rads/min.

12
Dose Rates
For a typical HDR remote afterloader,
the dose rate can be:
300 Gy/hr = 30,000
30 000 cGy/hr = 30,000
30 000 rads/hr = 500 rads/min
rads/min.

Currently, the highest dose rate

reported is about 700 rads per minute
at 1 cm.

13
Remote Afterloaders
Remote Afterloaders (also known as a
source delivery units or treatment
units) are only used for temporary
implants in a radiation oncology
department or clinic.

14
Remote Afterloaders

Currently, there are three HDR

remote afterloaders available in the
market:
1. The GammaMed
2. VariSource™
3. microSelectron

15
Remote Afterloaders

„ The GammaMed marketed by Varian

Associates (Palo Alto, CA)

The Varian GammaMed remote

afterloader

16
Remote Afterloaders

„ VariSource™marketed by Varian
Associates (Palo Alto, CA)

The Varian VariSource™ remote

afterloader.

17
Remote Afterloaders

„ microSelectron marketed by Nucletron

(Veenendaal, The Netherlands).

The Nucletron MicroSelectron V2

high dose rate remote afterloader

18
Remote Afterloaders

19
Remote Afterloaders

Treatment units today can move the

source through hollow applicators,
which usuallyy consist of needles or
catheters

20
 Remote Afterloaders

All available HDR

remote afterloaders
consist of the same
general components
even though they differ
in their technological
specifications

21
22
 Component-Radioactive
Source
The radionuclide currently used for all
HDR remote afterloaders is Ir-192. Since
Ir-92 has a high specific activity of about
450 Ci/gg and an averageg ggamma-rayy
energy of 0.38 MeV, a 10 Ci sources made
out of this radioactive material can be
smaller and easier to shield compared to
Co-60 or Cs-137 (both of which have
higher energy gamma rays).

23
Component -Shielded Safe
• A stepping-source remote afterloader uses an Ir-
192 source of 5 to 10 Ci to provide a dose rate of
up to 700 cGy/min (at 1 cm from the source). A
shielded safe made of tungsten
g or depleted
p
uranium houses the source when it is not in use.

24
Component- Source Drive
Mechanism

The drive mechanism causes the

source cable to advance from the
shielded safe along gap path
constrained by transfer tubes to the
first treated dwell position in the
applicator attached to the first
channel.

25
Component-Indexer
A view of the access panel of the
microSelectron treatment unit. The
emergency off button
(in the center of the box at the
bottom of the picture) on the unit is
to withdraw the source into the
shielded safe.

Also shown are the manual

retraction cranks for the radioactive
source cable on either side of the
keyhole in the middle, for the source
on the left and the check cable on
the right.

26
Component-Indexer

The back panel of the

VariSource™ showing
VariSource
the crank for manual
source retraction in an
emergency.

27
 Component-Transfer Tubes
As the name suggests, transfer tubes
are long flexible tubes that act as a
conduit to transfer the source from the
remote afterloader to the applicators or
catheters
th t for
f treatment.
t t t One
O end d off the
th
transfer tube is attached to the indexer
of the treatment unit, while the other
end is attached to the interstitial,
intracavitary or transluminal applicators.

28
Component - Treatment
Control Station

The treatment control station allows

the user to select the dwell positions
and dwell times for each channel .

Channel

29
 Component -Treatment
Control Panel
The treatment control station transfers the data to
the treatment control panel. A hard or soft START
button initiates the execution of the treatment
according to the program. In addition, there is an
INTERRUPT button,
b tt which
hi h when
h pressed d retracts
t t
the source and stops the timer, allowing the user to
enter the treatment room without receiving radiation
exposure. A RESUME or START button resumes
the treatment from the time and the dwell position
where it was interrupted. A master EMERGENCY
OFF button initiates the high-torque DC emergency
motor to retract the source
30
Patient Applicators

In order to deliver the source precisely to the target

area, a number of different types of catheters and
applicators have been developed. Three such
applicators are shown above.
31
Patient Applicators
With respect to safety, the applicator must
be coupled to the afterloader guide tube in
such a way that no obstruction or
constriction of the source wire occurs.
Two important criteria for these
applicators are that safety
considerations not be neglected, and
that patient comfort be maximized for
compliance during the treatment.
32
Patient Applicators
Some of the suitable tumor sites for HDR
brachytherapy are as follows:
„ Abdomen
„ Bile duct
„ Brain
„ Breast
„ Cervix
„ Colon
„ Endobronchial
„ Endometrium
„ Esophagus
„ Head and Neck
„ Pancreas
„ Prostate

33
Patient Applicators

„ Almost all applicators designed for

LDR manual afterloading have been
adapted
p for HDR use with a
mechanism to connect them to a
transfer tube from the afterloader
device.

34
Patient Applicators

„ The connection has mechanical

interlocks to ensure that the applicator
is correctlyy positioned
p and connected.
The interlocks prevent wrong
connections.

35
Patient Applicators

„ The applicator, transfer tube, and

afterloader device are a closed system
to avoid the ppossibility
y of the source
becoming dislodged in the patient or
exiting into the air before reaching the
target region.

36
Intracavitary
„ Intracavitary
applicators use
specific transfer
tubes designed to
be the same overall
length but to have
different interlocks
for each treatment
channel to avoid
connection errors..
37
 Intraluminal
„ Intraluminal applicators
usually connect directly with
the treatment unit using a
specific adapter
adapter. These
applicators can be 5 or 6
French diameter, blind ended,
flexible tubes (disposable); or
they can have a specific
design (esophageal
applicator).
38
 Interstitial
„ Interstitial applicators can be rigid or flexible. The
rigid stainless steel needles are of different lengths
and require specific transfer tubes. The needles can
be reused after sterilization. Using a template for
the implantation with a fixed predetermined
geometry allows us of standard dose distribution.
The thin, flexible disposable plastic tube require
different transfer tubes

39
Characteristics of major applicators

Category Type Dosimetr Reusabl Clinical Use

y e
Intracavitar Ring Preplan Yes Gynecological
y Applicator
Intracavitar Fletcher type No Yes Gynecological
y preplan
Interstitial Rigid Preplan Yes Interstitial/Molds
templates
Interstitial Neddles No Yes Interstitial
preplan
Interstitial Plastic tubes No No Interstitial
preplan
Intraluminal Lumen Preplan No Lung/Bile
Catheter Duct/Esophagus
Intraluminal Esophageal Preplan Yes Esophagus

40
Safety Features of Remote
Afterloaders
HDR remote afterloaders are complicated devices
containing very high activity radioactive sources.
Because of the high dose rate and the short
treatment times, serious accidents can happen
quickly.
i kl All these
th units
it h
have many safety
f t ffeatures
t
and operational interlocks to prevent errant source
movement or to facilitate rapid operator response in
the event of a system failure. Manufacturers make
sure the all new installations have all the safety
features described in 10 CFR Part 35.615.

41
 Emergency Switches
Numerous EMERGENCY OFF switches are
located at convenient places and easily
accessible, in case a situation arises. One
EMERGENCY OFF switch is located on the
control
co t o pa
panel.
e Another
ot e EMERGENCY
G C O OFF butto
button
is located on the top of the remote afterloader
treatment head. Vendors usually install one or two
emergency switches in the walls of the treatment
room. In the event a treatment is initiated with
someone other than the patient in the treatment
room, that person can stop the treatment and
retract the source by pressing the EMERGENCY
OFF button.

42
Emergency Crank
„ All treatment units have
emergency cranks to
retract the source cable
manually if the source fails
t retract
to t t normally ll and
d th
the
emergency motor also
fails to reel in the source..
Using the crank requires
the operator to enter the
room with the source
unshielded.

43
Door Interlock
„ Interlock switches prevent initiation of a treatment
with the door open. When a treatment is in
progress, opening the door interrupts the treatment.
This safety feature protects the medical personnel
f
from radiation
di ti exposure iin ththe eventt somebody
b d
enters the treatment room without the knowledge of
the operator. If a door is inadvertently opened
during the treatment, the treatment is interrupted
and the source returns to the safe. The treatment
can be resumed at the same point where it was
interrupted by closing the door and pressing the
START or the RESUME button at the control panel.
44
Audio/Visual System

All HDR suites must be equipped with

a closed-circuit television system or
shielded windows and/or mirrors for
observing the patient, and a two-way
audio system to communicate with the
patient during treatment.

45
 Radiation Monitor and
treatment on Indicator
• Three separate independent systems alert
personnel when the source is not shielded. One
radiation detector is part of the treatment unit and
indicates on the control panel when it detects
radiation.
di ti A independent
An i d d t unit,
it usually
ll mounted
t d on
the treatment room wall with displays both inside
and outside the room, also alerts the operator and
other personnel when the radioactive source is out
of the safe. A treatment on indicator outside the
room, usually over the door, activates when the
source is exposed, also indicating that a treatment
is in progress.
46
Backup Battery

• In case of a power failure during the

treatment, the machine is equipped
with a backup p battery
y to p
provide
retraction of the source to its safe.
The batteries should be tested with
each source change.

47
System Failure
„ In the event the radioactive source fails to retract
after termination, interruption, pushing the
emergency off switch, or cranking the stepper motor
manually,y, the immediate priority
p y is to remove the
source from the patient.

48
Table 2 gives the exposure rates at various
distances from a 10 Ci 192Ir source.

49
 Advantages and
disadvantages of HDR

„ Less exposure for radiation workers

„ Dose optimization
„ Outpatient Treatment
„ Better documentation

50
 Advantages and
disadvantages of HDR

Gynecological treatments have these

additional advantages:
„ Less movement of the applicator
„ Dose Reduction to Normal Tissue
„ Applicator Size

51
 Advantages and
disadvantages of HDR
Some of the disadvantages of HDR
Brachytherapy are:
„ Cost
„ C
Complexity
l it
„ Compressed time frame
„ Radiobiology - As the dose rate increases,
the radiosensitivity (damage per unit dose)
increases for both normal tissues and
tumors.
52
 Advantages and
disadvantages of HDR
Overcoming this radiobiological handicap requires
the use of the advantages of optimization,
geometry, stability, and dose reduction to normal
tissues, in addition to fractionation. As with external
b
beam radiotherapy
di th (d
(delivered
li d with
ith a lilinear
accelerator, which also operates at high dose rates)
spreading the treatments over many smaller
fractions delivered over several days reduces the
difference in radiosensitivity between the tumor and
the normal tissues.

53
 Personnel Responsibilities
and Training

„ Title 10 CFR Part 35.690 addresses the

requirements for Authorized Users of
remote afterloader units. The wording of
thi section
this ti h has created
t d some confusion
f i ffor
radiation oncology departments because of
the specific training required of the
authorized user. First of all, the authorized
user is always a physician. Secondly, this
physician will satisfy training requirements.
54
Authorized Users

„ Most authorized users will be radiation

oncologists who have taken a training
course from the vendor of the remote
afterloader unit or from a medical
physicist. All authorized users must be
on the radioactive license.

55
The training
requirements for an
Authorized
Medical
Physicists are
listed in 10 CFR
Part 35.51

56
Training - Policies & Procedures

„ The duties and responsibilities of the

physicians, medical physicists,
dosimetrists, nurses and radiation
th
therapists
i t are explained
l i d iin th
the policies
li i
and procedures for the radiation
oncology department or clinic. These
are written with input from physicians,
administrators, physicists, nurses,
dosimetrists and therapists.
57
Responsibility

„ Although each hospital or

clinic may differ in some
aspects, the major roles of
each member of the clinical
team are as follows:

58
The physician is personally
responsible for the following:

1. Patient selection
2. Written directive for each patient's radiation dose
3. Design and approval of the treatment plan
4
4. S l i
Selection, iinsertion
i and d removall off the
h treatment
applicator and approval of all simulation films
5. Direction of treatment delivery
6. Safety of the patient

59
Physicist

„ The Physicist (along with the Radiation

Safety Officer) is responsible for
ensuring g that the remote afterloader
unit is stored in a properly shielded
location, and that all regulations
concerning radiation safety are strictly
enforced.

60
Physicist
„ The physicist will perform the acceptance testing of
the entire HDR Remote Afterloader System,
including the treatment planning system. He/she is
also responsible for writing quality control
procedures
d ffor control
t l off the
th radioactive
di ti source
during initial installation and subsequent source
exchanges. He/she is responsible for calibration of
the source and entering this information into the
treatment planning computer and the remote
afterloader treatment console

61
 Physicist
. On treatment day the physicist's
responsibility includes:
1. Treatment day check of safety interlocks and
operational features, source position, and timer
accuracy
2. Treatment planning and file management
3. Supervision along with the physician of the
control console operation during delivery of the
treatment
4. Survey of the patient before and after the
treatment
5. Radiation safety and documentation
In addition, the authorized medical physicist is frequently
involved with the calculation and administration of the
radiation dose. 62
RSO
The Radiation Safety Officer is directly responsible for the safe
use of all radioactive sources and devices. The RSO
communicates with the regulatory agencies concerning safety
issues and is responsible for what is written in the license
concerning the HDR program. The RSO will also review the
credentials of the radiation oncologist before adding him or her
to the license as an authorized user. The RSO will often be
involved in the design of the HDR facility and may perform the
first area survey when the remote afterloader is installed. The
RSO will review the installation before the first medical use to
make sure that all the requirements of the license have been
met. The RSO should review all procedures and emergency
plans.

63
The Radiation Oncology Nurse is responsible for
the nursing care of the patient which may include
scheduling and notification of the patient. Other
duties include:

1. Applicator cleaning, storage, and

sterilization
2. Patient education and preparation
3 Assisting the physician with insertion of
3.
applicators
4. Care of the patient during treatment
planning
5. Assisting the physician with removal of
applicators
6. Documentation in patient chart
 The Radiation Technology Therapist
(RTT)is responsible for operation of the
x-ray equipment used in preparation of the
dosimetry films or the CT images used for
treatment planning. These duties include:
1. Transfer of the patient to and from the CT or
x-ray couch
2
2. Checking immobilization of the applicator to
prevent movement
3. Placement of markers such as a Foley
balloon or rectal marker
4. Selection of technique and exposure of films
as directed by the physicist
5. Labeling of films with essential information
Treatment Planning System

„ A treatment planning system is supplied by

a vendor, as a part of the remote
afterloading system. It consists of the
h d
hardware ((computer,
t printer,
i t etc.)
t ) and
d th
the
proprietary vendor software to perform the
treatment plans. Before first medical use
the physicist will test all the features of the
treatment planning system to make sure it is
operating as designed.
66
 Treatment Planning System
A common denominator to all is that images of
the patient with the applicator in treatment
position are required for treatment planning.
Before taking the images (CTs or x-rays)
dummy (inert) metal markers, that emulate all
the possible dwell positions for the source, are
i
inserted
t d iin th
the applicator.
li t Aft
After th
the iimages are
taken, and approved by the physician, the
dummy markers are removed and the patient is
made as comfortable as possible while the
physicist uses the images to prepare the
treatment plan

67
 Treatment Planning System
„ The goal of the plan is to use the
images to visualize the patient in 3
dimensions and to identify a target
volume or organ in that dataset.
Next all the possible dwell locations
are identified and the planning
starts.
t t Using
U i ththe ttools
l provided
id d iin
the program, the physicist attempts
to find the best combination of dwell
positions and dwell times to deliver
the prescribed dose to the target
while sparing as much normal tissue
as possible. All this must be
accomplished quickly and
accurately.

68
HDR QA Program

„ Quality Assurance (QA) programs are

established to minimize untoward events
caused by the malfunction of the machine or
h
human error. S
Suchh programs bbecome
exceedingly important in HDR
brachytherapy because the planning and
the treatments tend to happen very quickly,
increasing the likelihood of accidents and
mistakes.
69
HDR QA Program
„ QA is performed at various intervals: some
for each patient, some once each treatment
day, and others with each source change.
Moreover, for HDR machines, the USNRC
(2003) mandates
d t th thatt users meett certain
t i
standards, including education and training
on operating the machine, emergency
procedures, radiation monitoring,
pretreatment safety checks, safe and
accurate delivery of the treatment, and
monthly/initial calibration of the source

70
HDR QA Program

„ Acceptance testing, which is

performed upon acquiring the
equipment,
q p , is different from p
periodic
quality control testing. Acceptance
testing is a comprehensive set of tests
which allow the physicist to evaluate
the behavior and function of the
devices
71
Verification of dose variables

„ a. Checking the strength of the

p
source in the console computer,
compared with that projected from the
initial calibration based on radioactive
decay.
„ b. Checking the accuracy of the
controlling timer
72
Verification of proper operation of
safety features

„ a. Checking the electrical interlocks at the treatment room

entrance.
„ b. Checking the source exposure (detector) indicator lights on the
remote afterloader unit, on the control console, and in the treatment
room.
„ c. Checking g the p
patient viewing
g monitor and intercom systems.
y
„ d. Check that the emergency response equipment is present.
„ e. Check the radiation monitors used to indicate the source
position;
„ f. Check the clock (date and time) in the console computer.
„ g. Checking the operation of a handheld radiation detector.
„ h. Checking the operation of the check cable runs and interlocks.
„ i. Checking the operation of the emergency off and treatment
interrupt buttons

73
Verification of position control (requires film
and a source QA phantom).

„ a. Checking that the source goes to

the location programmed.
„ b. Checking g coincidence between the
programmed positions and the
respective positions indicated by
imaging markers.
„ c. Checking consistent movement of
the source
74
Additional QC- Some quality control tests
are performed monthly by the physicist (although
this is no longer required by federal regulations).

„ The tests in the daily or pre-treatment QA in

addition to the following:
1. Verification of source position and step size with an autoradiograph
a. An x-ray is taken of dummy seed markers in a QA phantom to show the dwell
location superimposed
p p on the marker lines of the p phantom.
b. The phantom is carefully moved to the treatment area, the dummy marker is
removed and the QA phantom is connected
c. The treatment unit is connected to the QA phantom and the source is stepped
through different source positions in the phantom, specifically at the location
of every other marker. This produces an autoradiograph of the source that
overlays every other seed in the dummy wire. The agreement should be
within 1 mm.
2. Timer offset, timer accuracy and timer linearity
3. Constancy check of the chamber and calibration
a. Since this is not a full calibration, Pion from the last source change is used.

75
QC Quarterly

More rigorous quality control tests

are performed quarterly, because
that is the frequency with which
HDR sources are replaced.
These tests are only performed by
the physicist and include a
calibration of the new source.
76
Source Change

„ The half life of Iridium is approximately

74 days. Most service contracts allow
for replacement of the source every
quarter
t (approximately
( i t l 90 d days).
) At
this time the 10 Curie source has
decayed to about 4 Curie and the
treatments take more than twice as
long to deliver the same dose
compared to a new source.
77
Calibrations
Title 10 CFR Part 35.633 requires that an authorized medical
physicist perform a calibration of the HDR source:
{ Before the first medical use of the unit;
{ Before medical use under the following conditions:
{ Following g replacement
p of the source or following
g
reinstallation of the unit in a new location outside the
facility; and
{ Following any repair of the unit that includes removal of
the source or major repair of the components
associated with the source exposure assembly; and
{ At intervals not exceeding 1 quarter for high dose-rate,
medium dose-rate, and pulsed dose-rate remote
afterloader units with sources whose half-life exceeds
75 days; and
{ At intervals not exceeding 1 year for low dose-rate
remote afterloader units. 78
Calibrations
The calibration must include the following:
„ The output within ± 5 percent;
„ Source positioning accuracy to within ±1 millimeter;
„ Source retraction with backupp battery
y upon
p p power
failure;
„ Length of the source transfer tubes;
„ Timer accuracy and linearity over the typical range
of use;
„ Length of the applicators; and
„ Function of the source transfer tubes, applicators,
and transfer tube-applicator interfaces.

79
Calibrations

„ The source calibration of the HDR Ir-

192 is performed in accordance with
the AAPM p protocol TG21. The
calibration quantity that is endorsed by
the AAPM is air kerma strength, which
is directly related to the dose in the
patient.

80
HDR Room Design

81
HDR Brachytherapy Workload

The Brachytherapy workload can be calculated with:

W = Γ fmed A t
where:

Γ is the gamma constant (0.47 R/(Ci hr) at 1 cm

fmed is the Roentgen to cGy conversion factor (0.96 cGy/R)
A is the activity of the Ir-192 source = 10 Ci
t is
t = (no of pts/week)(ave. treatment time per pt).
and is typically 300 to 400 min/week for a busy site.

82
 HDR Brachytherapy
Workload

„ An easier method is to multiply the

number of treatment minutes per week
by the dose rate for HDR (up to 700
cGy
G per minute).
i t ) In
I many shielding
hi ldi
calculations 10 Gy/min at 1 cm is
used.
„ W = (10 Gy/min)(300 min/wk)
„ W = 3,000 Gy/wk
83
 HDR Brachytherapy
Workload

„ At the console area, the barrier is

„ B = P D2/WUT
„ B = (1 Gy/wk)(D2)/(3
Gy/wk)(D2)/(3,000
000
Gy/wk)

84
 HDR Brachytherapy
Workload

„ If the distance, D, between the console

and the unit is 5 ft, D = 1.524 m
„ B = (1.524)(1.524)/3000
(1 524)(1 524)/3000 = .0007742
0007742
„ NTVL = log10 (1/B) = log10 (1291.7)
= 3.11 TVL
„ NTVL = (3.11)(14.7 cm concrete) =
45.7 cm concrete = 10 in concrete
85
Shielding
„ Proper design of a high dose rate facility will increase patient
safety and comfort, provide adequate space for work and
storage, and protect staff from exposure to radiation. The first
requirement is radiation safety. Once a potential treatment
room is identified or designed, the first consideration is
adequate shielding. How much barrier material (typically
concrete and/or lead) is necessary? An old cobalt room or
linac room is ideal because it usually has much more shielding
than is required (since they were designed to house a much
more energetic source of radiation). Whether new design or
old construction is used, shielding calculations need to be
performed to determine what is needed. The same shielding
calculations used for external beam are used for high dose
rate Brachytherapy

86
Shielding-The same shielding calculations used for
external beam are used for high dose rate Brachytherapy

B=P D2 / WUT
B = attenuation required by the barrier
P = permissible dose (2 10-5 Gy/wk)
W = workload in Gy/wk
D= distance from the exposed source in meters
U = fraction of time that a particular wall or area
is exposed to radiation (=1 for Brachytherapy)
T = fraction of time someone is on the other
side of the barrier (=1 for the console area)

87
Shielding

88
Shielding
„ In Brachytherapy the radiation is (typically) inside the patient,
therefore, the amount of exposure near the patient is
attenuated by the patient’s body. Depending on how close to
the surface the radiation is (or how much tissue it has to travel
through to reach the skin), the attenuation can vary from 30%
(10 cm) to 65% (25 cm) for Iridium. Attenuation by the patient
is commonly neglected in shielding calculations. Essentially,
we assume that it is a surface application.
„ Based on the assumptions made in the shielding
calculations, careful consideration of the thickness of the floor
and ceilings, and the nature of the occupied areas directly
below and above, is needed to determine if supplemental
shielding is required.

89
 License Requirements for
the Room
„ 10 CFR, Part 35.12 addresses the
requirements for a new license or license
renewal. Part of this requirement is a
diagram of the facility
facility. One of the most
important elements of the room design is the
door. The door must be installed in such a
manner that it controls access to the
treatment room. That means it can be
locked when not in use and can be
observed by the operator when it is in use.
90
 License Requirements for
the Room
Furthermore the door must have an
electrical interlock that will:
„ prevent the operator from initiating the
y
treatment cycle unless the treatment room
entrance door is closed;
„ cause the sealed source to be shielded
promptly when the door is opened; and
„ prevent the sealed source from being
exposed following an interlock interruption
until the door is closed and the source “on-
off” control is reset at the console.
91
Security
„ Security of the sources and the remote
afterloader is a major concern. The remote
afterloader must be stored behind a locked
door. Sources are exchanged quarterly and
a new source arrivesi a ffew days
d b
before
f th
the
source change is scheduled. This 10 Curie
source must be stored in a hot lab or a
locked (and properly labeled) room. The
decayed source (about 4 Curie) must also
be stored until it is shipped back to the
manufacturer

92
Storage

„ Storage space is required for the

dosimetry equipment used for QA and
for the manyy applicators,
pp , transfer
tubes and additional apparatus used
for treatments. An area to wash the
applicators once they are removed
from the patient is desirable.

93
 Room Design
„ This room has the
advantage of a maze that
shields anyone entering the
room from the remote
afterloader unit. It also
provides protection for the
therapist when he or she is
taking x-rays of the patient
on the treatment table in the
center of the room.
94
 Room
„ If your facility has space for
HDR, but no vault, NELCO
offers a pre-fabricated vault,
Figure 9, that can be installed
in a space about 100 sq. ft. (7
ft deep by 10
10.5 5 ft wide by 8
8.5
5
ft high). The 50,000-pound
unit, designed for 2-hour
weekly source exposure time,
has all necessary features of
an HDR vault and can be
installed in 3 weeks.
Pre-Fab HDR Suite

95
Integrated brachytherapy unit

„ Nucletron features an integrated

brachytherapy unit, designed to
perform patient preparation, applicator
i
insertion,
ti iimaging,
i iisodose
d
computation, delivery, and verification
in the unit. The imaging equipment
allows fluoroscopy from all directions.
The unit is designed for those centers
with large brachytherapy services.
96
Integrated brachytherapy unit

97
Mobile HDR Facilities
„ A mobile HRD remote afterloader unit can service
several facilities on the same license or on separate
licenses. Each location in the facility where the
HDR unit is used must satisfy the same safety and
regulatory
g ypprovisions as a p
permanent location.
Federal technical requirements for a mobile service
(USNRC 2002) are described in 10 CFR 35.647.
„ Two types of vans are available: The "mobile vault"
full-service van that contains not only the HDR
remote afterloader and ancillary equipment but also
the fully shielded treatment vault, and the van that
transports only the HDR remote afterloader and
limited ancillary equipment
98
Mobile HDR Facilities
„ Applicable transport regulations
must be rigorously adhered to and
those transporting must have
received hazard materials
(HAZMAT) training. The van must
have antitheft alarms; the HDR
remote afterloader cannot be left
i th
in the van overnight.
i ht ThThe van
must satisfy either applicable state
or federal Department of
Transportation requirements for
the transport of radioactive
materials. Docking (unloading)
facilities (tailgate lifts, dock lifts,
etc.) may be necessary for the
safe transfer of the HDR remote
afterloaders to and from the van at
each treatment facility.

99