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AAPM 89 (TG43) - Dose Specification For 103Pd and 125I Interstitial Brachytherapy
AAPM 89 (TG43) - Dose Specification For 103Pd and 125I Interstitial Brachytherapy
103
Key words: Pd, 125I, permanent interstitial brachytherapy, air-kerma strength, dose prescriptions
1424 Med. Phys. 32 „5…, May 2005 0094-2405/2005/32„5…/1424/16/$22.50 © 2005 Am. Assoc. Phys. Med. 1424
1425 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1425
1426
Medical Physics, Vol. 32, No. 5, May 2005
TABLE I. Prescription and reference dose calculation parameters for the model 200
1993⬍ t 艋 present ⌳04D,N99S = 0.686 gL,04D共r兲 an,04D共r兲 Light seed era Equation 共6兲 used
2004 TG-43 report Monroe and Williamson 2002
¯ an,04D = 0.862
recommendation as recommended by Monroe-Williamson data per 2004 TG-43
Average of Nath and Monroe TG-43 2004 recommendation
103
recommendations Continued use of TG 43 1995
Pd and
relative dose functions
recommended
125
3 / 01艋 t 艋 present ⌳01D,N99S = 0.68 g P,95D共r兲
¯ an,95D = 0.90 Unchanged from
I interstitial brachytherapy
Theragenics implements corrected above except that
WAFAC standard measured ⌳00D,N99Sadjusted by 5%.
t ⬎ tTG43U1 , 04D dosimetry, TG-43 2004 ⌳04D,N99S = 0.686 gL,04D共r兲 an,04D共r兲 Equation 共6兲 assumed
Report data but an,04D共r兲 and gL,04D GL共r兲
1426
1427 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1427
TABLE II. Dummy TG-43 dose calculation parameters for the Model 200
Pd-103 source.
0.912
0.880
0.979
0.957
0.975
1.000
D60
Heavy seed Light seed
0.880
0.979
0.957
0.980
1.000
0.911
TABLE III. Prescription and reference dose calculation parameters. tTG43U1⬎ March 2004 denotes the date on which the revised TG-43 recommendations were implemented.
D90
0.40 1.403 1.412
0.50 1.288 1.284
0.60 1.229 1.228
0.75 1.143 1.143
0.80 1.107 1.114
1.00 1.000 1.000
1.50 0.762 0.761
2.00 0.572 0.571
2.50 0.426 0.426
approximation
4.00 0.174 0.173
0.907
0.876
0.974
0.953
0.996
1.000
5.00 0.095 9 0.094 4
6.00 0.052 9 0.051 8
7.00 0.033 0 0.028 4
7.50 0.023 1 0.022 3
10.00 0.007 35 0.006 70
0.887
0.987
0.966
1.000
1.000
activity, Aapp,T88, denotes the quantity measured by Theragen-
ics™ assay, where the “T” of the subscript “Tnn” denotes
Theragenics™ and “nn” denotes the year that the 109Cd stan-
dard, to which the measurement is traceable, e.g., 1992 for
the “T92” 109Cd standard, was implemented. Note that
Aapp,Tnn is fundamentally different from apparent activity as
defined by the AAPM,13 Aapp,N99, which is a quantity derived
from NIST’s 1999 standard, SK,N99. The vendor’s apparent
activity assay can be related to the vendor’s air-kerma t ⬎ tTG43U1 04D dosimetry parameters and recommended
strength by
3 / 00⬍ t 艋 3 / 01 AAPM 2000 dosimetry parameters
共1兲
Averaging approximation
energy expended per ion pair created, 共W / e兲, take the nu-
merical values recommended by the AAPM.13
Because of the 463.3 day half life of 109Cd,14 four succes-
sive calibration sources were used during the period 1988–
1997. Pairwise sequential intercomparisons between the old
and replacement standards permitted changes in SK,Tnn rela-
tive to SK,N99 to be reconstructed.1 Prior to implementing the
T97 calibration source in October 1997, these variations
were less than 2%.
1429
Medical Physics, Vol. 32, No. 5, May 2005
Prescription
DxTx DxRx
DRx
t 共Gy兲 共Gy兲
5/88–3/90
4/90–3/93
Heavy seed production 共Cd source #1兲
95D, T90S
0.877
0.890
0.911 关0.899兴b
1.039 共1.048兲a 关1.079兴b
117.7
115
115
其
4/93–11/93 End of heavy seed era: light seed production begins 共Cd 95D, T90S 0.890 0.989 共1.010兲a 关1.064兴b 113.7 115
source #2兲
0.880 关0.899兴b 共Dt兲Rx
Tx
= 0.990 DxTx = 114 Gy
12/93–6/94 Light seed production 共Cd source #3兲 95D, T93S 0.861 1.022 共1.010兲a 关1.099兴b 117.5 115
7/94–9/22/97 Light seed production 共Cd source #4兲 95D, T94S 0.894 0.984 共1.010兲a 关1.059兴b 113.2 115
9/22/97–3/19/00 SK,T97 standard shifts by 9.7%, 共Cd source #5兲 95D, T97S 0.807 0.880 关0.899兴 b
1.090 共1.102兲 关1.172兴
a b
125 115
103
Pd and
3/20/00–3/4/01 Theragenics replaces SK,T97 with SK,N99 and AAPM 2000 00D, N99S 1.053 0.979 关1.000兴b 0.930 共0.940兲a 关1.000兴b 116 125
dose parameters 00D, N99S accepted
0.957 共0.990兲a
125
3/5/01–tTG43U1 Corrected SK,N99 standard implemented and DRC 01D, N99S 1.00 0.957 120 125
I interstitial brachytherapy
revised
⬎tTG43U1 04D, N99S parameters 04D, N99S 1.00 1.000 1.000 共1.000兲a 125 125
共approved 1D formalism兲
⬎tTG43U1 04D, N99S parameters 04D, N99S 1.00 0.980 共1.000兲a 0.980 共1.000兲 122 125
共old 1D formalism兲
a
Ratios from original Monroe and Williamson paper.
b
Ratios from AAPM 2000 Guidance.
1429
1430 Williamson et al.: Dose specification for 103
Pd and 125
I interstitial brachytherapy 1430
cally elevated by seed model-dependent factors of up to 7%, vised dose-calculation formalism are used in the analysis to
relative to measurements performed before and after this pe- follow as “reference dosimetry parameters,” i.e., used to es-
riod. Many models of 125I and 103Pd sources were unfortu- timate “administered dose.”
nately affected by this anomaly. For the Model 200 source, The dose ratios recommended in the AAPM 2000 report1
the SK,N99 measurements were elevated by 5.3% during this take into account the developments described in Secs. II A 1,
period 共see Appendix A, Sec. 6, and Appendix B, Sec. 2.3 of II A 2, II A 4, II A 5, and II A 6 above. The revised analysis,
the TG-43 2004 update6兲. Unfortunately, the AAPM 20001 presented in the following, takes into account the remaining
recommendations were based upon these erroneous measure- phenomena: heavy- versus light-seed design 共Sec. II A 3兲,
ments. This measurement error was corrected by NIST in the 1999 WAFAC errors 共Sec. II A 7兲, and dosimetry parameters
first quarter of 2000. and formalism revised as described by the new TG-43 pro-
As with other seed models, PEBD coordinated the transi- tocol 共Sec. II A 8兲.
tion to the corrected WAFAC standard with NIST, Theragen-
ics, and the ADCLs on 5 March, 2001. Since each such tran- B. Generalized formalism for evaluation of
sition was vendor- and model-specific, no AAPM report was administered-to-prescribed dose ratios
published to advise the community and vendors were respon-
sible for communicating the relevant action plan to their cli- To evaluate the ratio of administered dose, DTx, to pre-
ents. For the Model 200 source, the corrected WAFAC stan- scribed dose, DRx, the methodology described by Monroe
dard was implemented simultaneously by the vendor, NIST, and Williamson7 has been adopted. Their analysis accounts
and ADCLs on 5 March, 2001 共Appendix A, Sec. 6 of the for changes in the dose-rate constant used for treatment plan-
TG-43 2004 update6兲. As part of this process, the measured ning and time-dependent discrepancies between vendor and
dose-rate constant of Nath et al.,3 which was normalized to NIST source-strength specifications as does the original
erroneous WAFAC measurements, was increased by 5.3% to AAPM 2000 analysis. In addition, Monroe and Williamson7
compensate for the correction. This led to a new revised accounted for the dosimetric effect of Model 200 seed inter-
average dose-rate constant ⌳01D,N99S = 0.68 cGy h−1 · U−1. At nal geometry changes caused by the transition from the
that time, AAPM advised the community to continue using heavy seed to the light seed production process, the NIST
the 2000 administered-to-prescribed dose ratios and guid- 1999 WAFAC anomaly, and the dose-parameter revisions
ance derived therefrom until further notice. It is assumed that published in the 2004 TG43 protocol, none of which were
these recommendations remain operative up to the present anticipated by the AAPM 2000 Report.1 The influence of
time. seed manufacturing process changes on the DTx / DRx ratio
was incorporated into the analysis by introducing separate
time-dependent reference dosimetry parameters for the light
8. Revised dosimetry parameters and the updated and heavy seeds. The current report adapts the Monroe–
TG-43 protocol „March 2004… Williamson analysis with the addition of more sophisticated
Since implementation of the 2000 AAPM guidance dose-averaging techniques. In addition, this report consis-
report,1 the Model 200 dosimetry parameters have been fur- tently uses the 1D dose-calculation formalism recommended
ther refined. A comprehensive Monte Carlo-based study7 was by the 2004 AAPM report6 in contrast to the Monroe–
published by Monroe and Williamson, which contained Williamson analysis which used the old TG43 dose-
TG-43 dosimetry parameters for both the “light” and calculation formalism.9
“heavy” seed designs. In addition, Yue and Nath17 published The mean administered-to-prescribed dose ratio, 共Dt兲RxTx
, is
冋冓 冔册 冋
measured light-seed 2D anisotropy functions which were in given by
excellent agreement with Monroe’s calculations. Both stud-
ies confirmed that the 1995 TG-439 anisotropy functions,
yielding a ¯ an,95D = 0.90, significantly overestimated the
共Dt兲Rx
Tx
= t 共r
Dref ៝兲
Dt 共r៝兲
Rx ·
SK,N99 t⬘ ⬎ 3/01
SK,t
册, 共3兲
source isotropy compared to more recent publications, which where t and t⬘ refer to the past time in question and current
imply ¯ an,04D = 0.862. time, respectively; 共Dt兲Rx Tx
denotes the administered-to-
In March 2004, a major update of the TG-43 protocol was prescribed dose ratio for time t, and D共r៝兲 denotes the calcu-
published.6 It contained revised data, designated by the sub- lated dose at position r៝ in an implant. The bracketed quantity,
script “04D,” for the Model 200 seed. The recommended 具X典, denotes the result of spatially averaging the indicated
⌳04D,N99S is nearly identical to ⌳01D,N99S. New radial dose quantity over the appropriate region within the planning tar-
functions, 1D anisotropy functions, and 2D anisotropy func- get volume 共PTV兲 of a typical implant. Various approaches
tions 共based on Monroe’s simulations7兲 were recommended to spatial averaging are discussed in the following. The quan-
for clinical use. In addition, the dose-calculation formalism tity Dref ៝兲 denotes the administered dose at location r៝, or
t 共r
itself was modified. The revised formalism requires use of dose actually delivered, during the period t as approximated
the 1D anisotropy function rather than the anisotropy con- by the selected reference dosimetry parameters. Reference
stant,
¯ an,04D and specifies a new method of calculating doses parameters are those considered, based upon current knowl-
at small distances. It also advises users to adopt the line- edge, to provide the most accurate and physically rigorous
source geometry function over the point-source function. method of retrospectively and prospectively calculating dose
Both the new relative “04D” dosimetry parameters and re- in an implant. The quantity DRx ៝兲 denotes the corresponding
t 共r
prescribed dose derived from the dosimetry parameters in D. Reference dosimetry parameters
use at time t. The last factor on the right of Eq. 共3兲 is the ratio
For the currently available “light” seed, the parameters
of “true” air-kerma strength 共SK,N99 as implemented by Ther-
recommended by the TG-43 2004 update6 were used. The
agenics after March 2001 or as implemented in January 1999
radial dose function, gL,04D共r兲, recommended therein was de-
for Model 6711 sources兲 to the source-strength standard, SK,t,
rived from the Monte Carlo study by Monroe and
accepted as definitive during the time period t for seeds of
Williamson.7 The function gL,04D共r兲 was defined over the dis-
identical physical construction emitting identical quantities
tance range 0.1–10 cm and the 1D anisotropy function,
of radiation. Assuming that the new TG-43 report was imple-
an,04D共r兲, over the distance range 0.25 to 10 cm. The rec-
mented at time tTG43U1 ⬎ 3 / 04, Eq. 共3兲 can be used to derive
ommended dose rate constant, ⌳04D,N99S, was obtained by
the prescribed dose, DtRx ⬘⬎tTG43U1
, for use with the reference
averaging the measured value3 共corrected for the 1999
dosimetry parameters and the current air-kerma strength anomaly in SK,N99兲 with the corresponding Monte Carlo
standard that ensures that patients will continue to receive estimate.7 These data are summarized in Table I.
the same delivered dose 共as estimated by retrospective appli- For the “heavy” seed, the 2004 TG-43 report makes no
cation of reference dosimetry parameters兲 as otherwise iden- recommendations regarding dosimetry parameters. The rela-
tical patients planned with “t-era” dose distributions, source tive Monte Carlo data by Monroe and Williamson7 are as-
strength standards, and prescribed doses: sumed, an approach consistent with the AAPM consensus
DtTx⬘⬎t 共r៝ 兩 SK,N99 , 04D , DtRx
⬘⬎tTG43U1
兲 = D Tx
t ៝
共r 兩 S K,t , tD , D t 兲.
Rx
data-formation methodology. This methodology offers two
TG43U1
Hence choices for estimating the consensus heavy seed dose-rate
Rx
Dt⬘⬎t = 共Dt兲Rx
Tx
· DRx 共4兲 constant: 共i兲 average the Monroe–Williamson Monte Carlo
t ,
TG43U1 value 共⌳02D,N99S
MC
= 0.694兲 with the average of the Chiu–Tsao16
15
and Meigooni measurements 共⌳ ¯ TLD
where DRx t is the prescribed dose 共in units of Gy兲 and the 90D,N99S = 0.650兲 or 共ii兲 re-
arguments to the right of the vertical line indicate the dosi- ject the experimental measurements as candidate data sets
metric data and SK standard used for treatment planning used and use the Monte Carlo value without modification:
at time t. Generally, the clinical goal is to reproduce the ⌳04D,N99S = ⌳02D,N99S
MC
= 0.694. Because the Chiu–Tsao and
clinical outcomes of a previously treated group of patients in Meigooni measurements were normalized to source-strength
the face of significant dose-calculation and source-strength measurements that are not traceable to the current NIST SK
standard revisions. Obviously, it is necessary to carefully standard and because these pioneering works do not adhere
match the prescribed dose, dose-calculation formalism and to modern standards of experimental dosimetry,6 the AAPM
parameters, and SK standardization procedures to the clinical believes that using the unmodified Monte Carlo dose-rate
experience one is trying to duplicate. In the sections to fol- constant, i.e., option 共ii兲, provides the least uncertain esti-
low, each factor of Eq. 共3兲, along with its method of evalu- mate of the heavy seed reference dose-rate constant consis-
ation, will be defined. tent with the AAPM consensus-formation methodology.
Reference administered doses were calculated according
to the 1D dose calculation formalism recommended by the
2004 TG-43 report 共Eq. 共11兲兲兴.6 For a single seed, the refer-
C. Air-kerma strength standard revisions
t 共r
ence dose rate, Ḋref ៝兲, is given by
The air-kerma strength ratios, SK,t / SK,N99, used in the
analysis of 103Pd seed dosimetry are given by ៝兲
t 共r
Ḋref
SK,t GL共r, 0兲
SK,N99 = SK,N99 · ⌳04D,N99S · · gL,04D共r兲 · an,04D共r兲.
GL共r0, 0兲
冦
0.886, t 艋 9/97, SK,t = S̄K,T88–94 共6兲
0.807, 9/97 ⬍ t 艋 3/00, SK,t = SK,T97
= Equation 共6兲 was implemented on a commercial treatment
1.053, 3/00 ⬍ t 艋 3/01, SK,t = SK,N99 in 1999 planning system 共VariSeed Planning Workstaion, Version
1.000, t ⬎ 3/01, SK,t = SK,N99 in 2000 7.1, Varian Medical Corporation, Inc., Palo Alto, CA兲 for
共5兲 permanent seed implants. However, this treatment planning
system, like many others, does not support the implementa-
These values were based on the ratios given in the AAPM tion of Eq. 共6兲 since it allows only the point-source geometry
2000 report1 corrected by the magnitude 共1.053兲 of the 1999 function to be used in its implementation of the 1D TG43
WAFAC measurement anomaly, which resulted in elevated formalism. PEBD notes that this planning system, as well as
Model 200 seed calibrations by Theragenics and the ADCLs many other commercial systems, would have supported
during the period 3 / 00⬍ t 艋 3 / 01. For the period 1988 to implementation of the allowed but not recommended 1D for-
September 1997, our analysis uses the SK,t / SK,N99 ratio spe- malism 关Eq. 共10兲 of the 2004 TG-43 protocol, using G P共r兲
cific to each cadmium calibration source actually used 共see rather than GL共r , 0兲兴. This option closely approximates Eq.
Table IV兲, not the average ratio, S̄K.T88–94 / SK,N99, indicated 共6兲 although it is less accurate at small distances, e.g., r
by Eq. 共5兲. ⬍ 1 cm. To implement Eq. 共6兲, it was necessary to “fool” the
t 共r
Ḋref ៝兲 = SK,N99 · ⌳04D,N99S · 冉冊r0
r
2
¯⬘ ,
· g⬘共r兲 · an 共7兲
mula, Eq. 共6兲, preferred by the 2004 TG-43 report兴, and the
following parameters: ⌳tD,XtS = ⌳04D,N99S, gtD共r兲 = gL,04D共r兲
¯ ⬘ = ¯⬘
and an,tD
¯ an,04D, where 7
an,04D = 0.862. The latter option
where the primed quantities denote dummy parameters, is equivalent to using the anisotropy constant-based 1D for-
listed in Table II, designed to reproduce the dose rates pre- malism given by Eq. D1 of the 2004 TG-43 report, a formal-
dicted by Eq. 共6兲 down to distances of 0.1 cm using the ism widely used in the past but no longer endorsed by the
point-source geometry function and the now-forbidden an- AAPM. The dosimetric parameters assumed for various eras
isotropy constant. Letting rmin be the smallest distance for are summarized in Table I. This report assumes that 1995
which an,04D共r兲 is tabulated, these ratios are selected so as TG-43 compatible parameters were used throughout the era
to force Eq. 共7兲 to agree with the currently recommended 1988–2000 even though the TG-43 report was published in
model, Eq. 共6兲, for each of the tabulated data entries. 1995, the same assumption made by the AAPM 2000 report.1
For the case r 艌 rmin, this leads to the following equiva- The 1995 TG-43 report recommendations were based upon
lences: averaging the two measured dose-rate constants published at
g⬘共r兩r 艌 rmin兲 =
GL共r, 0兲 an,04D共r兲 r
·
GL共r0, 0兲 an,04D共r0兲 r0
冉冊 2
· gL,04D共r兲,
that time.15,16 Those readers who wish to duplicate a particu-
lar institutional implant experience based on pre-1995 im-
plants should confirm that the prescription parameters as-
sumed by this report are reasonable approximations to the
¯ ⬘ = an,04D共r0兲
共8兲 institution’s dose-calculation procedures.
an
Ḋ共r៝兲 = SK · ⌳ · 冉 冊
rmin
r
2
·
GL共rmin, 0兲
GL共r0, 0兲
· gL共r兲 · an共rmin兲.
F. Dose-averaging procedures
=
GL共r0, 0兲
·
r0
冉 冊
GL共rmin, 0兲 rmin 2
· gL,04D共r兲 ·
an,04D共rmin兲
an,04D共r0兲
,
will be described in turn.
¯ ⬘ = an,04D共r0兲.
共10兲
an
1. Radial dose function equivalence approximation
To evaluate the dummy quantities defined by Eqs. 共8兲 and
„RDA…
共10兲, the tabulated 1D anisotropy functions6,7 were interpo-
lated onto the finer radial dose function grid by applying The RDA approach has been used by most administered-
linear interpolation to the quantity r2 · GL共r , 0兲 · an,04D共r兲 to-prescribed dose ratio analyses published to date, including
and then converting the result back to an,04D共r兲. This proce- the AAPM 2000 Report1 and the Monroe–Williamson
dure is based upon Williamson’s approximation18 ¯ an article.7 RDA assumes that Eqs. 共6兲 and 共11兲 yield equivalent
⬇ r2 · GL共r , 0兲 · an,04D共r兲. The resultant values of g⬘共r兲 and dose-rate predictions and that gt共r兲 ⬇ g95D共r兲. In addition, it
¯ ⬘ are given in Table II.
ignores other subtleties such as errors arising from mixing
an
G P共r兲 and gL共r兲 data in the same equation. Given these as-
sumptions, mean dose ratio assumes a very simple form:
具DRx ៝兲典
t 共r
= 共⌳ ·
¯ an兲Rx
t
具f典G共r兲 = 兺
N
ri艌1 cm
f共ri兲 · G共ri兲 冒兺 N
ri艌1 cm
G共ri兲, 共14兲
冦
0.74 · 0.90 = 共⌳ ·
¯ an兲95D,T88S , t 艋 3/00 where 兵ri其i=1
N
denotes the set of radial distances 艌1 cm for
which g共r兲 and an共r兲 are specified; G共ri兲 is the inverse
0.665 · 0.90 = 共⌳ ·
¯ an兲00D,N99S , 3/00 ⬍ t 艋 3/01
square-law weighting factor; and f共r兲 is the function to be
=
冓 冔
0.68 · 0.90 = 共⌳ ·
¯ an兲01D,N99S , 3/01 ⬍ t 艋 tTG43U1 averaged. The mean-dose ratio is then given by
0.686 · 0.862 = 共⌳ ·
¯ an兲04D,N99S , t ⬎ tTG43U1 , t 共r
Dref ៝兲 具Dref
t 共r៝兲典
=
Dt 共r៝兲
Rx
具Dt 共r៝兲典
Rx
⌳04D,N99S具an,04D共r兲 · gL,04D共r兲典GL共r兲
= . 共15兲
t 共r
具Dref ៝兲典 = 共⌳ ·
¯ an兲Ref ¯ an,t具gt共r兲典共r−2兲
⌳tD,XtS ·
再
t
0.694 · 0.884 heavy seed, t 艋 1993 This approach is identical to that recommended in 2004
= 共13兲
0.686 · 0.862 light seed, t ⬎ 1993. TG-43 report for estimating the now-forbidden anisotropy
constant. It was found that 具f典G共r兲 was quite sensitive to the
兵ri其i=1
N
grid assumed. Hence all averages, both for planned
and reference doses, were based on the choice 兵ri其i=1 N
再
L
The simple RDA approximation is not consistent with the
2004 TG-43 report guidance, which recommends using the 0.694 · 0.6554 = 0.4548 heavy seed, t 艋 1993
=
1D anisotropy function over the anisotropy constant. Nor 0.686 · 0.6399 = 0.4390 light seed, t ⬎ 1993.
does it account for the differences between g95D共r兲 and
共16兲
g04D共r兲 data recommended by the new report. To accommo-
date these changes, a generalized single-seed averaging pro- Since the prescribed dose distribution is calculated by Eq.
cedure was explored, defined by t 共r
共11兲, then 具DRx ៝兲典 becomes
冦
0.74 · 0.90 · 0.7529 = 0.5014, 95D, t 艋 3/00
0.665 · 0.90 · 0.7529 = 0.4506, 00D, 3/00 ⬍ t 艋 3/01
具DRx ៝兲典
t 共r = ⌳tD,XtS ·
¯ an,t具gt共r兲典共r−2兲 = 0.68 · 0.90 · 0.7529 = 0.4608, 01D, 3/01 ⬍ t 艋 tTG43U1 共17兲
0.686 · 0.862 · 7483 = 0.4425, 04Dg P,04D共r兲, t ⬎ tTG43U1
0.686 · 0.862 · 7455 = 0.4408, 04DgL,04D共r兲, t ⬎ tTG43U1 ,
case of the reference dosimetry calculations, the dummy pa- evaluated by CIA, on the dose in multiples of D90 for the
rameters summarized in Table II were used, which yields implant having the largest volume. For all three primary
doses equivalent to Eq. 共6兲. comparisons of reference and prescription dosimetry param-
As our results 共see Sec. III below兲 show that the mean eters 共the others can be obtained by scaling the graphs by the
dose ratio is constant within 1% for doses ranging from appropriate dose-rate constant ratio兲, the mean dose ratio is
0.25D90 to 1.8D90, D90 and D60 were extracted from the re- virtually constant between 0.5D90 and 2D90, which includes
sultant prostate DVHs for the four patients to derive the the peripheral layers of the target most relevant to clinical
mean dose ratios recommended by this report: dose prescription. Figure 2 shows the dependence of the dose
冓 冔 t 共r
Dref ៝兲
Dt 共r៝兲
Rx =
1
兺
4
共DXX,i兲ref,t
4 i=1 共DXX,i兲Rx,t
, 共18兲
ratio on spatial position in the transverse bisecting plane of
the implant. As illustrated by Figs. 1 and 2, at doses below
0.25D90, the mean dose ratio increases. As the commercial
planning system exports dose values as 16 bit integers scaled
where XX denotes either 90% or 60% of the prostate volume,
from zero to the maximum dose, this behavior arises from
and DXX,i represents the corresponding DVH statistic from
integer truncation. The uncertainty introduced by discretiza-
the ith sample implant.
tion of doses is less than 0.2% in the therapeutic dose range.
III. RESULTS Very near the seeds, Figs. 1 and 2 indicate that the dose
103 ratios are much larger and more variable. The
A. Reference-to-prescription dose ratios for Pd
共DXX,i兲ref,t / 共DXX,i兲Rx,t ratios were found to be nearly indepen-
brachytherapy
dent of the implant geometry, i, showing a maximum range
Figure 1 illustrates the dependence of mean dose ratio, as of 0.001 over the four implants for both D60 and D90.
t 共r
FIG. 2. Plots of the dose ratio, Dref ៝兲 / DRx ៝兲 as a function of position in the transverse 共top兲 and sagittal 共bottom兲 planes bisecting the center of the implanted
t 共r
volume for sample clinical implant No. 1. The 95D prescription dose parameters and formalism 关Eq. 共11兲兴 are compared to the light seed reference 共04D兲 dose
parameters.
FIG. 3. Plot illustrating the variation of the delivered dose for prescribed doses of 115 and 125 Gy as a function of time for the Model 200 103Pd source. After
2000, delivered doses are plotted for prescribed doses of 115 Gy 共solid line兲 and 125 Gy 共broken line兲. For illustration only, we have assumed tTG43U1
= 7 / 05. For post-tTG43U1 implants, the plot assumes that the AAPM preferred 1D dose-calculation model is used 关Eq. 共6兲兴.
Table III compares the mean reference-to-prescribed dose certainty of clinical dose calculation, it is prudent to recom-
ratios for the RDA, GFSA, and CIA averaging methods. mend the clinical implant averaging technique for perform-
With the exception of one case 共comparison of ¯ an- and ing future assessments of this type.
an共r兲-based formalisms using 04D data兲, all estimates agree
within 1.5%. Generally, the RDF approximation overesti-
mates the CIA 具Dref ៝兲 / DRx ៝兲典 value by about 1% while B. Administered-to-prescribed dose ratios
t 共r t 共r
GFSA results in a 0.5% underestimate. For all cases, the D90 The final 共Dt兲Rx
Tx
ratios recommended in this report, as es-
and D60 specification parameters produce virtually identical timated by the CIA technique, are listed in Table IV and
CIA estimates. However, in the ¯ an vs an共r兲 formalism plotted in Fig. 3, along with the corresponding values from
comparison case, the CIA dose-ratio estimate is 1.6% and the 2000 AAPM report1 and the Monroe paper.7 In addition,
2% smaller than the RDA and GFSA estimates, respectively. the time-weighted average 共Dt兲Rx Tx
ratios for the heavy seed
Since the same dosimetry data are used by all three methods, 共1988–1993兲 and pre-9/97 light seed 共1993–1997兲 eras are
the difference between GFSA and CIA must arise from the tabulated. Compared to the 2000 AAPM report, the revised
different formalisms, Eqs. 共6兲 and 共11兲, used in the denomi- ratios for the heavy seed and pre-9/97 light seed eras are
nator and numerator, respectively, of these two methods. The 3.8% and 7.1% smaller, respectively. Thus, a dose of 115 Gy
discrepancy suggests that the r−2 weighting scheme for r prescribed in the periods 1988–1993 and 1993–1997 yields
艌 1 cm gives a biased estimate of the average single-seed administered doses of 118 and 114 Gy, respectively, in con-
calculation distance characteristic of clinical implants. In the trast to the average administered dose of 124 Gy estimated
1988–present comparisons, this effect could have been by AAPM in 2000.1 The revised 9 / 97 to 3 / 00 dose ratio is
masked by differences in radial dose function in the prescrip- 7% smaller than that recommended by the 2000 Report, re-
tion versus reference eras. While the discrepancies among sulting in an administered dose of 124 Gy compared to 135
these three methods are small in relation to the overall un- Gy. Using the revised dose ratios recommended by this re-
port, a prescribed dose of 125 Gy5 delivered during the 3 / 00 are not large. The comparison of the RDA and GFSA dose-
to 3 / 01 era 共following WAFAC implementation by Ther- rate analyses in Table V shows that these errors influence the
agenics but preceding correction for the 1999 NIST measure- administered-to-prescribed dose ratios by at most 1%.
ment anomalies兲, corresponds to a delivered dose of 116 Gy, The 1995 TG-43 report recommended a dose rate constant
which is 7% lower than the 2000 Report estimate. Following of 0.88, which was mathematically modified to 0.98 in 1999,
Theragenics’ implementation of the corrected SK,N99 standard to accommodate implementation of the 1999 NIST
and the associated dose-rate constant adjustment in 3 / 01, standard.8 The 2004 TG-43 report further revises this value
this difference was reduced to a 4% underdose, i.e., 125 Gy to 0.965, which almost exactly compensates for the changes
prescribed corresponds to a delivery of 120 Gy. The major in
¯ an from 1995 to 2004. As a result, the changes in deliv-
causes of these revised ratios are the 5.3% error caused by ered dose from the introduction of the Model 6711 seed to
the 1999 NIST WAFAC anomaly for the Model 200 source the present have been less than 0.5% and can safely be ig-
共which was partially mitigated by the revision of the dose- nored. These data are summarized in Table V.
rate constant from 0.665 to 0.68兲 and the adoption of revised
2D anisotropy functions, which resulted in a change in an-
isotropy constant from 0.90 to 0.862. These two changes IV. DISCUSSION AND CONCLUSIONS
were first evaluated by Monroe and Williamson7 in 2002, but The methodology for analyzing the impact of the imple-
neither was anticipated by the 2000 report. For institutions mentation of new dose calculation parameters, formalism,
that implement the revised TG43 formalism, Eq. 共6兲, and and changes in source strength calibration standards, pre-
associated dosimetry parameters6 共next-to-last line, Table IV兲 sented here, was developed originally by Dr. Williamson and
without adjusting the prescribed dose, the delivered dose will Dr. Todor at Virginia Commonwealth University. Later, it
increase by 4%, from 120 to 125 Gy. For those who imple- was reviewed, reformulated, and incorporated into this report
ment the revised dosimetry parameters using the old TG43 by the AAPM PEBD subcommittee. This document was re-
1-D formalism, Eq. 共11兲, the administered dose will increase viewed and approved by the AAPM PEBD Subcommittee,
by 1.7%, from 120 to 122 Gy 共last line, Table IV兲. Radiation Therapy Committee, and Science Council. Hence
this report represents the official position of the AAPM on
C. 125
I Model 6711 source the recommendations for the impact of the implementation
of 2004 TG-43 update on the dose delivered by interstitial
As is the case with palladium, the history of iodine seed brachytherapy sources.
dosimetry is closely related to the history of a single seed For this analysis, we selected four typical prostate im-
model, the Amersham Model 6711 seed. It is well understood plants because the most popular application of interstitial
that the original prescribed dose of 160 Gy, used from 1985 brachytherapy continues to be organ-confined early stage
until 1995, was based on dosimetry parameters21 that were prostate cancer. That the doses used in the actual treatment of
changed by the publication of the 1995 TG-43 report. The the four patients differ from the commonly prescribed mono-
result was to change the prescribed dose to 144 Gy,8 and therapy dose of 125 Gy for 103Pd prostate implants does not
from 1995 to the present, most institutions have followed impact this analysis, since absolute source strength and dose
this change. do not influence the estimated dose ratios. Of the eight
The manufacturer of the 6711 seed did not adopt the NIST sources presented in the 2004 TG-43 update, our analysis
1999 air-kerma standard through the transfer of a calibrated considered only the 125I Model 6711 source and 103Pd Model
source, but instead mathematically implemented an adjust- 200 source because the vast majority of papers documenting
ment of 0.897. Consequently, the NIST measurement the clinical efficacy of permanent prostate brachytherapy,
anomaly 共⫹5.1% for the Model 6711 seed兲 of 1999 that af- representing decades of clinical experience, are based upon
fected the vendor calibrations of the Model 200 and many these sources. Brachytherapy of prostate cancer has become
other source types did not influence Amersham calibrations the treatment of choice for selected patients because of ex-
of the Model 6711 seed. Therefore, only one transition was cellent rates of local control with minimal treatment related
made in the determination of air-kerma strength of this seed; toxicity. With such a successful therapeutic option, it is criti-
that of the introduction of the NIST 1999 standard. cal that any changes in dose delivery techniques, including
It is recognized that the incorrect NIST 1999 standard was changes in dose calculation parameters and formalism, as
disseminated to the ADCLs, who may have passed it along to well as procedures used in establishing source strength,
customers, who may then have adjusted the strengths of should be analyzed critically in order not to compromise the
seeds delivered to them by the manufacturer, but this is not therapeutic implant in potentially curable patient popula-
known with any certainty. Thus, this possibility is ignored tions. This is the motivation behind this rather densely writ-
for this analysis. ten and complex analysis.
For the 6711 seed, an,04D共r兲 is almost constant from 1 to As mentioned earlier, the 1999 NIST anomaly affected
5 cm, so that the anisotropy constant, ¯ an,04D, 0.943, was many interstitial brachytherapy sources, some by up to 7%.
used in a comparison of delivered doses via the RDA Although dose calculations for several source models were
method. This value is slightly different from the value of affected by 1999 WAFAC measurement anomalies compa-
0.93 recommended by the 1995 TG-43 report.9 The differ- rable to or greater than those affecting the Model 200 seed,
ences among the 83D, 95D, and 04D radial dose functions these sources are not considered by our analysis. Because
共Gy兲
these source models were relatively new products, any dose-
160
145
145
145
145
DxRx
delivery errors associated with their use are irrelevant to the
interpretation and duplication of the published and evaluated
144.4 共144.5兲
143.0 共144.7兲
143.0 共144.7兲
clinical experience. As discussed in more detail in Sec. III C
共Gy兲
145
145
DxTx
Model 6711 125I vendor calibrations were not affected by the
1999 SK,N99 measurement anomaly.
Three different methods for evaluating the impact of do-
0.902 共0.903兲a simetry changes on prostate implants were employed. The
0.987 共0.998兲
0.987 共0.998兲
1.000 共1.000兲
1.000 共1.000兲
RDA method is the simplest and the most clear intuitively in
共Dt兲Rx
Tx
0.987 共0.998兲
0.987 共0.998兲
1.000 共1.000兲
1.000 共1.000兲
contributions at different distances. The most comprehensive
Ⲑ
1.000
1.000
1.000
1.115
¯ an,04D共r兲 共old
¯ an,95D = 0.93
¯ an,95D = 0.93
共approved 1D formalism兲
kkD,yyS assumed by DRx
technique.
, as a function of year t and dosimetry data tD for
1D formalism兲
04D,N99S parameters
2000–present
1999–2000
⬎ Present
⬎ Present
implants that differ significantly from the geometry of typical tribution of the model 200 103Pd interstitial brachytherapy source,” Med.
Phys. 27, 643–654 共2000兲.
prostate volume implants, e.g., planar implants or eye 5
D. Beyer et al., “American Brachytherapy Society recommendations for
plaques. In such cases, it may be prudent to re-evaluate the clinical implementation of NIST-1999 standards for 共103兲palladium
t 共r
具Dref ជ兲 / DRx ជ兲典 ratio for the specific implant geometry in
t 共r brachytherapy,” Int. J. Radiat. Oncol., Biol., Phys. 47, 273–275 共2000兲.
6
question. M. J. Rivard et al., “Update of AAPM Task Group No. 43 Report: A
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adoption of the 2004 AAPM TG-43 report recommendations 7
J. I. Monroe and J. F. Williamson, “Monte Carlo-aided dosimetry of the
is a systematic change that would affect all patients under theragenics TheraSeed model 200 103Pd interstitial brachytherapy seed,”
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8
J. F. Williamson et al., “Guidance to users of Nycomed Amersham and
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vidual patient, especially considering the dose inhomogene- calibration changes: recommendations of the American Association of
ity within a tumor volume, can have a profound effect on the Physicists in Medicine Radiation Therapy Committee Ad Hoc Subcom-
efficacy of a treatment regimen. Thus, a careful consideration mittee on Low-Energy Seed Dosimetry,” Med. Phys. 26, 570–573
共1999兲.
of all clinical factors is necessary before making systematic 9
R. Nath et al., “Dosimetry of interstitial brachytherapy sources: Recom-
changes in dose prescription and dose delivered by a mendations of the AAPM Radiation Therapy Committee Task Group No.
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10
B. R. Prestidge et al., “Posttreatment biopsy results following interstitial
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If you have questions regarding the recommendations of Phys. 37, 31–39 共1997兲.
11
J. Sharkey et al., “Minimally invasive treatment for localized adenocar-
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Cancer Center, Houston, TX at 共713兲 792-3226. 12
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ACKNOWLEDGMENTS ment planning of 125I and 103Pd interstitial brachytherapy sources: Rec-
The authors would like to thank Dr. Ty Robin, Dr. Mary ommendations of the American Association of Physicists in Medicine
radiation therapy committee subcommittee on low-energy brachytherapy
Napolitano, and Joe Rodgers of Theragenics Corporation for source dosimetry,” Med. Phys. 26, 2529–2530 共1999兲.
their exceptionally detailed and helpful comments. 14
M. P. Unterweger et al., “Radionuclide Half-life Measurements 共National
Certain commercial equipment, instruments, or materials 15
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1 18
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21
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